RN ATI CAPSTONE PROCTORED COMPREHENSIVE ASSESSMENT 2023 B ATI
COMPREHENSIVE PRACTICE TEST B RATED A+ BEST REVIEW
A nurse is assessing a patient who received 2 units of packed RBCs 48 hours ago. Which of the following
findings should indicate to the nurse that the therapy has been effective?
Answer: Haemoglobin 14. 9 g/dl
The nurse should identify that packed RBCs are administered to patients who have a decreased level of
haemoglobin or hematocrit. This haemoglobin level is within the expected reference range of 14 to 18
g/dl for males and 12 to 16 g/dl for females, indicating the therapy has been effective.
A nurse working in a n emergency department is triaging four patients. Which of the following patients
should the nurse recommend for treatment first?
Answer: A middle adult patient who has unstable vital signs.
Using the stable versus unstable approach to patient care, the nurse should recommend priority treatment
for the patient who has unstable vital signs because this patient requires immediate treatment to reduce
the risk of further injury or possible death.
A nurse is caring for a patient who has fluid volume overload. Which of the following tasks should the
nurse delegate to the CNA?
Answer: Measure the patient’s daily weight
It is within the CNAs range of function to measure a patient’s daily weight, so the nurse should delegate
this task to them.
A nurse is preparing to administer mannitol 0. 2g/kg IV bolus over 5 min as a test dose to a patient who
has severe oliguria. The patient weighs 198lb. What is the amount in grams the nurse should administer?
Answer: 18 g
A nurse is conducting a physical examination for an adolescent and is assessing the range of motion of the
legs. Which of the following images indicates the adolescent is abducting the hip joint?
Answer: In the correct image, the adolescent is abduction the hip joint by moving the leg away from the
midline of the body.
A nurse is caring for a patient who has hyperthyroidism. Which of the following findings should the nurse
expect?
Answer: Tremors
Tremors are a manifestation of hyperthyroidism, along with tachycardia, diaphoresis, weight loss,
insomnia, and exophthalmia.
A nurse is assessing a school-aged child who has bacterial meningitis. Which of the following findings
should the nurse expect?
Answer: Nuchal rigidity
This is a manifestation of bacterial meningitis.
A nurse is assessing a newborn’s heart rate. Which of the following actions should the nurse take?
Answer: Auscultate the apical pulse at least 1 min.
The nurse should auscultate the apical pulse to obtain an accurate assessment of heartrate and rhythm.
Auscultation of a newborn’s heart sounds can be difficult because of the rapid rate and the transmission of
respiratory sounds.
A nurse is preparing to assist with a thoracentesis for a patient who has pleurisy. The nurse should plan to
perform which of the following actions?
Answer: Instruct the patient to avoid coughing during the procedure.
It is important for the nurse to remind the patient to avoid coughing and to lie still during a thoracentesis
to avoid puncturing the pleura.
A nurse in the ED is assessing a preschooler who has a facial laceration. The nurse should identify which
of the following findings as a potential indication of child sexual abuse?
Answer: The child exhibits discomfort while walking.
The nurse should identify this finding as a potential indication of child sexual abuse.
A nurse is preparing to teach about dietary management to a patient who has Crohn’s disease and an
entero enteric fistula. Which of the following nutrients should the nurse instruct the patient to decrease in
their diet?
Answer: Fiber
The nurse should instruct the patient to consume a low-fiber diet to reduce diarrhoea and inflammation.
A nurse is caring for a patient who has a prescription for a continuous passive motion (CPM) machine
following a total knee arthroplasty. Which of the following actions should the nurse take?
Answer: Turn off the CPM machine during mealtime.
This promotes patient comfort and dietary intake.
A nurse is preparing to initiate IV access for an older adult patient. Which of the following sites should
the nurse select when initiating the IV for the patient?
Answer: Radial vein of the inner arm.
This site will have adequate subcutaneous tissue
A nurse is developing a patient education program about osteoporosis for older adult patients. The nurse
should include which of the following variables as a risk factor for osteoporosis?
Answer: Sedentary lifestyle.
This is a risk factor for osteoporosis. The nurse should encourage older adult patients to engage in weightbearing exercises because they will promote bone health by Increasing calcium and phosphorus levels.
A nurse in an ED is caring for a child who has a fever and fluid-filled vesicles on the trunk and
extremities. Which of the following interventions should the nurse identify as the priority?
Answer: Initiate transmission-based precautions
When using the urgent versus nonurgent approach to patient care, the nurse should determine that the
priority action is to initiate transmission-based precautions for the child. The child most likely has
varicella. Therefore, the nurse should isolate the child to prevent the spread of the infection.
A nurse is caring for a patient who has a clogged percutaneous gastrostomy feeding tube. Which of the
following actions should the nurse take first?
Answer: Change the position of the patient.
When providing patient care, the nurse should use the least restrictive intervention first. Therefore, the
nurse should reposition the patient to remove any kinks in the tube, which can lead to clogging. If this
method is unsuccessful, the nurse should attempt to flush or aspirate the patient’s tube to remove the clog.
A home health care nurse is developing a teaching plan for a patient who has anew ileostomy.
Which of the following instructions should the nurse include?
Answer: Empty the appliance when it is one-third to one-half full.
The ileostomy pouch should be emptied when it is one-third to one-half full to prevents tool leakage and
skin irritation.
A nurse is reviewing the laboratory report of a patient who has end-stage kidney disease and received
haemodialysis 24 yr ago. Which of the following lab values should the nurse report to the provider?
Answer: Sodium 148 mEq/L
The nurse should report this sodium level because it is above the expected reference range of 136 to 145
mEq/L, indicating hypernatremia. patients who have kidney disease often retain sodium and require
sodium-restricted diets.
A nurse is caring for four patients. Which of the following tasks should the nurse delegate to a CNA?
Answer: Arrange the lunch tray for a patient who has a hip fracture.
Assisting a patient with meals is within the range of function of the CNA.
A nurse is preparing a patient for a paracentesis. Which of the following actions should the nurse take?
Answer: Instruct the patient to void.
The nurse should instruct the patient to void prior to the procedure because an empty bladder decreases
the risk of a bladder puncture and minimizes the patient’s discomfort during the procedure.
A nurse has received change of shift report on four assigned patients. For which of the following patients
should the nurse intervene to prevent a potential food and medication interaction?
Answer: A patient who is receiving an MAOI and is requesting a cheeseburger for dinner. This patient’s
food selection contains tyramine. patients prescribed an MAOI must restrict the intake of foods that
contain tyramine due to adverse effects, such as hypertension.
A nurse is planning care for a patient who has rheumatoid arthritis and has moderate to severe pain in
multiple joints. Which of the following actions should he nurse plan to take?
Answer: Allow for frequent rest periods throughout the day.
The nurse should encourage the patient to balance rest with exercise to maintain muscle strength, joint
function, and range of motion
A nurse is caring for a patient who is receiving continuous bladder irrigation following a transurethral
resection of the prostate. The patient reports bladder spasms, and the nurse observes a decreased urinary
output. Which of the following action should the nurse take?
Answer: Irrigate the catheter with 0. 9% sodium chloride irrigation.
Decreased urine output and bladder spasms indicate internal obstruction of the catheter. Therefore, the
nurse should irrigate the catheter with 0. 9% sodium chloride irrigation and notify the provider if the
obstruction does not clear.
A nurse is assessing a patient who has COPD. Which of the following findings should the nurse expect?
Answer: pH 7. 31
Respiratory acidosis is an expected finding for a patient who has COPD. The expected reference range of
pH is 7. 35-7. 45. A pH level of less than 7. 35 indicates acidosis. For a patient who has COPD, a decrease
in pH will be accompanied by an increase in the level of carbon dioxide over the expected reference range
of 35 to 45 mm Hg, indicating respiratory acidosis.
A nurse in a community centre is providing an educational session to a group of patients about ovarian
cancer. Which of the following manifestations of ovarian cancer should the nurse include in the teaching?
Answer: Abdominal bloating
The nurse should include the presence of abdominal bloating as an early manifestation of ovarian cancer.
Other manifestations include an increase in abdominal girth, pelvic or abdominal pain, early satiety, and
urinary frequency or urgency.
A nurse is caring for a patient who has active TB. Which of the following actions should the nurse plan to
take to prevent the transmission of the disease?
Answer: Have the patient wear a surgical mask while being transported outside the room. This will
prevent the transmission of the disease.
A nurse is caring for a group of patients. Which of the following patients should the nurse attend to first?
Answer: An older adult patient who is anxious and attempting to pull out an IV line.
This patient is at greater risk of injury.
An RN is observing an LPN and a CNA move a patient up in bed. For which of the following situations
should the nurse intervene?
Answer: The LPN and the CNA grasp the patient under his arms to lift him up in bed. They should not
grasp the patient under the arms when lifting, as this can result in shoulder dislocation or other injuries to
the patient. The RN should intervene and instruct the nurses to use a draw sheet or friction-reducing
device to lift the patient.
A nurse is preparing to administer insulin to a patient via a pen device. Which of the following actions
should the nurse take?
Answer: Hold the insulin pen device perpendicular to the patient’s skin to inject the medication. This
ensures the insulin enters the subcutaneous tissue.
A nurse is caring for a patient who has immunosuppression and a continuous IV infusion. Which of the
following actions should the nurse take?
Answer: Monitor the patient’s mouth every 8 hr.
Check for manifestations of infection, such as sores or lesions.
A nurse is providing teaching about advance directives to a middle-aged adult patient. Which of the
following patient responses indicates an understanding of the teaching?
Answer: “I can designate my partner as my health care surrogate. ”
This statement indicates that the patient recognizes that designating a health care surrogate is part of
advance directives
.
A nurse is assessing a patient following a vaginal delivery and notes heavy lochia and a boggy fundus.
Which of the following medications should the nurse expect to administer?
Answer: Oxytocin
This is a hormone that stimulates uterine contractions, to decrease vaginal bleeding.
A nurse manager is planning to use a democratic leadership style with then uses on the unit. Which of the
following actions by the nurse manager demonstrates a democratic leadership style?
Answer: Seeks input from the other nurses.
This includes members of the team when making decisions and encourages staff members to participate
in the decision-making process.
A nurse is assigning task roles for a group of patients in a community mental health clinic. Which of the
following tasks should the nurse assign to the member of the group functioning as the orienteer?
Answer: Noting the progress of the group toward assigned goals. This is the task of the orienteer.
A nurse is creating a plan of care for a newly admitted child. Which of the following actions should the
nurse include in the plan? See Exhibit button Administer high-dose antibiotic therapy.
Answer: Children who have cystic fibrosis metabolize antibiotics more rapidly and require higher doses
of antibiotics to help fight aggressive infections such as Burkholderia cepacia.
A nurse is caring for a newborn immediately after delivery. Which of the following interventions should
the nurse implement to prevent heat loss by conduction?
Answer: Use a protective cover on the scale when weighing the infant.
Heat loss by conduction is a loss of heat between the newborn’s skin and the coolers surface beneath it.
A nurse is caring for a patient who had abdominal surgery 24 hr ago. Which of the following actions is
the nurse’s priority?
Answer: Assist with deep breathing and coughing.
The priority action the nurse should take when using the airway, breathing, circulation approach to patient
care is to assist the patient with deep breathing and coughing, which reduces the risk of postop
pneumonia.
A nurse in an outpatient mental health clinic is caring for four patients. The nurse should recognize that
which of the following patients is effectively using sublimation as a defense mechanism?
Answer: A patient who channels their energy into a new hobby following the loss of their job.
Channeling negative feelings over the loss of their job into a new hobby is using the defense mechanism
of sublimation.
A nurse is assessing f or correct placement of a patient’s NG feeding tube prior to administering a bolus
feeding. Which of the following actions should the nurse take?
Answer: Aspirate contents from the tube and verify the pH level.
The nurse should verify that the pH level of the patient’s gastric aspirate is less than 5 To determine
proper placement.
An antepartum nurse is caring for four patients. For which of the following patients should the nurse
initiate seizure precautions?
Answer: The nurse should initiate seizure precautions for a patient with severe preeclampsia or
eclampsia. These conditions are associated with an increased risk of seizures. The patient's clinical
presentation, such as elevated blood pressure and proteinuria, can signal a heightened risk, warranting
seizure precautions to ensure safety and prompt intervention if a seizure occurs.
A nurse is providing discharge teaching to a patient who is to receive home oxygen therapy. Which of the
following instructions should the nurse include in the teaching?
Answer: Wear clothing made with cotton fabrics while oxygen is in use. Woolen and synthetic fabrics
can generate static electricity, which increases the risk of afire.
A nurse is providing teaching for a patient who has a fracture of the right fibula with a short-leg cast in
place and a new prescription for crutches. The patient is non-weight bearing for 6 weeks. Which of the
following instructions should the nurse include in the teaching?
Answer: Use the three-point gait.
This allows the patient to be mobile without bearing weight on the affected extremity.
A nurse is preparing to transfer a patient from the ICU to the medical floor. The patient was recently
weaned from mechanical ventilation following a pneumonectomy. Which of the following information
should the nurse include in the change-of-shift report?
Answer: The time of the patient’s last dose of pain medication.
The nurse should recognize than an effective handoff report provides a baseline of the patient’s status for
comparison and should include any recent changes or priority situations affecting the patient’s condition.
The time of the patient’s last dose of pain meds is important to include so the receiving nurse can
anticipate what time to give the next dose.
A nurse is assessing a n infant who has hydrocephalus and is 6 hr postop following placement of a
ventriculoperitoneal (VP) shunt. Which of the following findings should the nurse report to the provider?
Answer: Irritability when being held.
This is a manifestation of increased intracranial pressure, which is an indication that the VP shunt is
malfunctioning. This finding should be reported to the provider immediately.
A nurse is caring for a client who has a prescription for chlorpromazine. Which of the following finding
should the nurse identify as an indication that the medication is effective?
Answer: Decreased hallucinations.
This is an antipsychotic medication administered to decrease hallucinations and other manifestations of
schizophrenia.
A nurse is providing teaching about lithium to a patient who has bipolar disorder. Which of the following
statements should the nurse include in the teaching? “Notify your provider if you
Answer: experience increased thirst”
Increased thirst is a manifestation of lithium toxicity. The nurse should instruct the patient to report
increased thirst, vomiting, diarrhoea, or tremors to the provider.
A nurse caring for a patient who has a fecal impaction. Which of the following actions should the nurse
take when digitally evacuating the stool?
Answer: Insert a lubricated gloved finger and advance along the rectal wall. This is the correct way of
doing this.
A nurse is planning to delegate patient care tasks to a CNA. Which of the following tasks should the nurse
plan to delegate to the CNA?
Answer: Perform gastrostomy feedings through a patient’s established gastrostomy tube. This task is
within their range of function.
A nurse manager is preparing an educational session for nursing staff about how to provide cost- effective
care. Which of the following methods should the nurse include in the teaching?
Answer: Delegate non-nursing tasks to ancillary staff.
It is an effective method of providing high-quality, cost-effective care because this will allow additional
time for nurses to focus on skilled tasks.
A nurse on an inpatient m mental health unit is monitoring a visit between a patient who has a history of
aggressive b behaviour and the patient’s partner. Which of the following should the nurse identify as an
indication of potential violence?
Answer: The patient is pacing around the chair in which their partner is sitting.
Hyperactivity and pacing indicate that this patient is at risk for violent behaviour. The nurse should assess
the situation further and attempt to de-escalate the situation by speaking to the patient in a low, calm
voice using short sentences.
A nurse is caring for a client who has signed an informed consent form to receive electroconvulsive
therapy (ECT). The patient states to the nurse, “I’m not sure about this now. I’m afraid it’s too risky. ”
Which of the following responses should the nurse make?
Answer: “You have the right to change your mind about this p procedure at any time. ” The patient can
refuse to consent at any time for a procedure. The nurse is demonstrating advocacy by respecting the
patient’s wishes r regarding care.
A rural community health nurse is developing a plan to improve health care delivery for migrant
farmworkers. To identify health services data for this minority group, the nurse should gather information
from which of the following sources?
Answer: Agency for Healthcare Research and Quality
The goal of the Agency for Healthcare Research and Quality (AHRQ) is to improve the quality of health
care services for all populations, including low-income groups and minorities. This data should help the
nurse to develop an evidence-based plan to improve health care services for specific populations.
A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the
nurse report to the provider?
Answer: Nasal flaring.
This indicates respiratory distress. Signs are nasal flaring, retractions, and grunting.
A charge nurse is speaking with the partner of a patient. The partner states that the patient is not receiving
adequate care. Which of the following actions should the charge nurse take first to resolve the situation?
Answer: Ask the partner to list specific concerns.
The first action the nurse should take u sing the nursing process is to assess the situation by asking the
partner to list specific concerns.
A nurse is providing information to a patient immediately before his scheduled Romberg test. Which of
the following statements should the nurse make?
Answer: “I will be checking you once with your eyes open and once with them closed. ”
The Romberg test will be performed once with eyes open and once with eyes closed. This is performed to
assess balance and motor function.
A nurse is teaching a patient who is at 20 weeks of gestation about common discomforts associated with
pregnancy. Which of the following statements by the patient indicates an understanding of the teaching?
Answer: “I will wear a supportive bra overnight. ”
Wearing a supportive bra even while sleeping can promote comfort by providing support to enlarged
breasts during pregnancy.
A nurse is caring for a client who is taking valproic acid for seizure control. For which of the following
adverse effects should the nurse monitor and report?
Answer: Jaundice.
Monitor the patient for jaundice and report any indications to the provider. patients who take valproic acid
are at risk for liver damage, which can lead to jaundice.
A nurse is providing discharge instructions about newborn care to a patient who is postpartum. Which of
the following statements indicates to the nurse that the patient understands the teaching?
Answer: “I will cover my baby’s body when I wash her”
“I will use the bulb syringe first in her mouth and then in her nose”
Newborns are highly susceptible to heat loss. The patient should wrap the newborn in a towel when
washing the hair to minimize heat loss.
The patient should suction the newborn’s mouth first to remove secretions that the newborn could aspirate
when suctioning the nares.
A nurse on a mental health unit is conducting a mental status examination (MSE) on a newly admitted
patient. Which of the following components of the MSE is the priority for the nurse to assess?
Answer: Ideas of self-harm.
The greatest risk to this patient is injury from ideas of self-harm. The priority assessment the nurse should
make is to determine whether the patient has had suicidal or homicidalideas.
A nurse is preparing to administer lactated Ringer’s 1500 mL to infuse at 50 mL/hr. The drop factor of the
manual I V tubing is 15 gtt/min. The nurse should set the manual IV infusion to deliver how many
gtt/min?
Answer: 13 gtt/min
A nurse is providing teaching to a patient who has a new diagnosis of type 1 diabetes mellitus. The nurse
should instruct the patient to monitor for which of the following findings as a manifestation of
hypoglycemia?
Answer: Irritability
The nurse should instruct the patient to monitor for irritability, which can indicate decreased blood
glucose levels.
A nurse is providing teaching to a patient who is scheduled for ECT. The nurse should inform the patient
that which of the following is an adverse effect of ECT?
Answer: Short-term memory loss
This is a common adverse effect of ECT.
A charge nurse notices that one of the nurses on the shift frequently violates unit policies by taking an
extended amount of time for a break. Which of the following statements should the charge nurse make to
address this conflict?
Answer: “I would like to talk to you about the unit policies regarding break time. ”
The charge nurse is dealing with the conflict in a cooperative, positive manner by using this statement to
open the conversation in a nonthreatening way. The focus is on the length of the break time and is not a
personal affront.
A nurse in an emergency department is caring for a patient who is at 9 weeks of gestation and reports
nausea and vomiting for the past 2 days. Which of the following findings should the nurse expect?
Answer: Urine specific gravity 1. 052
The nurse should recognize this urine specific gravity is significantly elevated above the expected
reference range of 1. 005 to 1. 030. An increased urine specific gravity indicates dehydration from
vomiting.
A nurse is caring for an older adult patient who is experiencing chronic anorexia and is receiving general
tube feedings. Which of the following laboratory values indicates that the patient needs additional
nutrients added to the feeding?
Answer: Albumin 2. 8 g/dL
The nurse should recognize that an albumin level of less than 3. 5 g/dL indicates malnutrition and a need
for additional nutritional supplementation. The expected reference range for albumin is 3. 5 to 5 g/dL.
A nurse is conducting group therapy with patients who have breast cancer. The nurse should recognize
which of the following statements by a patient as an example of altruism?
Answer: “I told my doctor that I would like to start a support group for other women who are sicking my
community. ”
This statement indicates that the patient is demonstrating altruism by reaching out and helping others.
A nurse is providing dietary teaching to a patient who has a new prescription for phenelzine. Which of the
following food recommendations should the nurse make?
Answer: Broccoli, yogurt, cream cheese patients taking an MAOI should not eat foods that contain
tyramine. Fermented meat such as pepperoni and bologna are high in tyramine.
A nurse is assessing a patient for compartment syndrome. Which of the following findings should the
nurse expect?
Answer: Edema
Compartment syndrome causes increased pain, pallor, and paresthesias from increased edema in the
compartment involved.
A nurse is providing discharge teaching about disease management for a patient who has a new diagnosis
of type 1 diabetes mellitus. Which of the following activities is the nurse’s priority?
Answer: Ensure that the patient understands the medication regimen.
The priority action the nurse should take when using the safety vs risk reduction approach to patient care
is to ensure the patient understands the medication regimen. The greatest risk to the patient is the potential
to develop hypoglycemia or hyperglycemia, which can be life-threatening if treated incorrectly.
A nurse at an urgent care clinic is assessing a patient who reports impaired vision in one eye. Which of
the following reports by the patient should indicate to the nurse that the patient has a detached retina?
Answer: Floating dark spots
These are a manifestation of a detached retina due to bulges, folds, or holes in the affected retina.
A nurse on a med-surg unit is assessing a patient who has had a stroke. For which of the following
findings should the nurse initiate a referral for occupational therapy?
Answer: Difficulty performing ADLs
A referral for occupational therapy to teach the patient the skills necessary to become independent in
performing ADLs such as bathing, dressing, and eating.
A nurse is assessing a patient following a colonoscopy. Which of the following findings should indicate to
the nurse that the patient is hemorrhaging?
Answer: Rapid decrease in blood pressure
This is an indication of hemorrhage.
A nurse is caring for a client who recently signed an informed consent form to donate a kidney to her
sibling who had end-stage kidney disease. The donor states to the nurse, “I don’t want my brother to die,
but what if I need this kidney one day?” Which of the following responses should the nurse make?
Answer: “You’re afraid that your other kidney will fail at some point after the organ donation?” The
nurse is restating the patient’s statement, which lets the patient know that the nurse is listening and paying
attention to what the patient is communicating.
A nurse is assessing a patient who has pulmonary edema. Which of the following findings should the
nurse expect?
Answer: Pink, frothy sputum
A patient who has manifestations of pulmonary edema can have pink, frothy sputum due to fluid leaking
across the pulmonary capillaries and into the lung tissue.
A nurse administers an incorrect dose of medication to a patient. The nurse recognizes the error
immediately and completes an incident report. Which of the following facts related to the incident should
the nurse document in the patient’s medical record?
Answer: Time the medication was given
The nurse should document the time, the name of the med, the dose, and the route in which the med was
given on the patient’s MAR immediately after it was administered. The nurse should also document the
time that the incorrect med was administered to the patient in the incident report, as this is a fact directly
related to the occurrence.
A nurse is caring for a client who is post-op after receiving moderate (conscious) sedation. The patient
suddenly becomes restless and reports feeling lightheaded. Which of the following actions should the
nurse take?
Answer: Check the patient’s oxygen saturation level.
Restlessness and light headedness are indications of hypoxia. The nurse should check the patient’s
oxygen saturation level.
A nurse in an ED is assessing a school-aged child who was brought in by their parents and has scald burns
to both hands and wrists. The nurse suspects physical abuse. Which of the following actions should the
nurse take?
Answer: Contact Child Protective Services
The nurse has a legal responsibility to report suspected physical abuse to Child Protective Services.
A nurse is caring for a 2-month-old infant who has Hirschsprung disease (HD). Which of the following
areas should the nurse assess for manifestations of HD?
Answer: The nurse should assess the infant’s abdomen for distention and visible peristalsis, which are
manifestations of HD.
A nurse is admitting a patient to the psychiatric unit after attempting suicide. The patient states, “My
family does not care whether I live or die. ” Which of the following responses should the nurse make?
Answer: “How does this make you feel?”
This response encourages the patient to evaluate their feelings.
A nurse is providing discharge teaching for the parents of a preschool-age child who has a new
prescription for amoxicillin/clavulanate suspension. Which of the following instructions should the nurse
include in the teaching?
Answer: Shake the medication bottle well before each dose is given. Store the medication in the
refrigerator
Report diarrhea to the provider immediately
A nurse on a med surg unit is caring for a patient who has a new diagnosis of terminal cancer. The patient
tells the nurse that they would like to go home to be with family and loved ones. Which of the following
actions should the nurse take?
Answer: Make a referral for social services
As a patient advocate, the nurse should support the patient’s decisions and obtain a referral for social
services to ensure that the patient’s needs a t home are met. Social services can set up home care or
hospice care services for the patient if needed.
A nurse is assessing a patient who has a chest tube. Which of the following findings should the nurse
expect?
Answer: Occlusive dressing on the insertion site.
This prevents air from leaking and is an expected finding.
A nurse is preparing to transfer a patient who has had a stroke to a rehabilitation facility. The patient’s
family tells the nurse they are concerned about the level of care the patient will receive. Which of the
following actions should the nurse take?
Answer: Facilitate an interdisciplinary conference at the new facility for the family.
This will address the family’s concerns about providing optimal care for the patient.
A nurse is assessing a patient who has major depressive disorder and is taking amitriptyline. Which of the
following should the nurse identify as an adverse effect of the medication?
Answer: Blurred vision
This is an adverse effect of amitriptyline and the provider should be notified.
A charge nurse is providing an educational session about infection control for a group of staff nurses.
Which of the following statements by one of the staff nurses indicates an understanding of isolation
precautions?
Answer: “A patient who requires airborne precautions should be placed in a negative-pressure airflow
room. ” Airborne precautions require a negative-pressure airflow room that has at least 6-12 air exchanges
each hour using a HEPA filtration system.
A nurse is preparing to administer a blood transfusion to a patient. Which of the following procedures
should the nurse follow to ensure proper patient identification?
Answer: Verify the patient and blood product information with another licensed nurse.
The nurse should compare the blood product label against the medical record and the patient’s
identification number with another nurse to ensure the correct blood product is administered to the correct
patient.
A nurse in a mental health clinic is assessing a patient who has a history of seeking counselling for
relationship problems. The patient shows the nurse multiple superficial self-inflicted lacerations on their
for earns. The nurse should identify these behaviors as characteristics of which of the following
personality disorders?
Answer: Borderline
The nurse should identify that patients who have borderline personality disorder tend to be emotionally
unstable, have troubled interpersonal relationships, and often engage in harmful behaviors such as cutting,
substance use, and suicidal ideation.
A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling
off a step stool at home. Which of the following prescriptions should the nurse clarify with the provider?
Answer: Apply a cold pack to the patient’s ankle for 30 min/hr
The nurse should clarify a prescription for a cold pack to the patient’s ankle because type1 diabetes
mellitus is a contradiction for receiving cold therapy. A patient who has type 1 diabetes mellitus can have
impaired circulation due to arteriosclerosis and a loss of sensory perception due to neuropathy. Ice can
further impair circulation.
A nurse is teaching about adverse effects with a patient who is s tarting to take captopril. Which of the
following findings should the nurse identify a s an adverse effect of the medication to report to the
provider?
Answer: Cough
This is due to the buildup of bradykinin in the lungs. The patient should report this to the provider.
A nurse is reviewing the ABG values of a patient. The patient has a pH of 7. 2, PaCO2 of 60 mm Hg. and
HCO3 of 25 mEq/L. The nurse should identify that the patient has which of the following acid-base
imbalances?
Answer: Respiratory acidosis
A patient who has respiratory acidosis will have decreased pH below the expected reference range of 7.
35-7. 45, an increased PaCO2 above the expected reference range of 35-45 mm Hg, and an HCO3 within
the expected reference range of 22-26 mEq/L.
A nurse in a provider’s office is assessing an adolescent who has been taking ibuprofen for 6 months to
treat juvenile idiopathic arthritis. Which of the following questions should the nurse ask to assess for an
adverse effect of this med?
Answer: “Have you had any stomach pain or bloody stools?”
These are an indication of gastrointestinal bleeding, an adverse effect of ibuprofen.
A nurse in a pediatric unit has received a change-of-shift report for four children. Which of the following
children should the nurse assess first?
Answer: A 10-year-old child who is awaiting surgery f or an appendectomy and experienced sudden
relief from pain.
Using the urgent vs nonurgent approach to patient care, the nurse should determine that the patient to
assess first is the child awaiting an appendectomy who suddenly experiences pain relief as this can be an
indication of peritonitis from a ruptured appendix. The nurse should notify the provider immediately.
A nurse on an inpatient u nit is caring for a patient who has schizophrenia and recently started taking
risperidone. Which of the following actions should the nurse take?
Answer: Implement fall precautions for the patient.
Risperidone can cause orthostatic hypotension and dizziness, which can lead to falls. The nurse should
initiate fall precautions for the patient.
A nurse is assessing a patient who has decreased visual acuity due to cataracts. The nurse should identify
which of the following physiological changes is the cause of the patient’s visual loss?
Answer: Increased opacity of the lens
A cataract is a cloudy or opaque area in the lens of the eye that inhibits light penetration.
A nurse is caring for a client following a vacuum-assisted birth. The nurse should monitor The patient for
which of the following complications related to vacuum-assisted birth?
Answer: Cervical laceration
Complications are perineal, vaginal, or cervical lacerations.
A nurse is updating the plan of care for a patient who is 48 hr. post-op following a laryngectomyand is
unable to speak. Which of the following actions should the nurse plan to take first?
Answer: Determine the patient’s reading skills
Using the nursing process to assess the patient, determine the patient’s level of reading skills and
cognition. The nurse can best provide the patient with a variety of customized techniques to practice and
use after verbal skills are lost.
A nurse is caring for a school-aged child who has dehydration and is receiving an oral rehydration
solution. Which of the following lab results indicates that the treatment regimen is effective?
Answer: Serum sodium 138 mEq/L
Sodium level of 138 mEq/L, is within the expected reference range of 136-145 mEq/Land is an indication
that the child is responding to the oral rehydration solution.
A school nurse is notified of an emergency in which several children were injured following the collapse
of playground equipment. Upon arrival at the playground, which of the following actions should the nurse
take first?
Answer: Survey the scene for potential hazards to staff and children.
Using the nursing process, assess the situation. By surveying the scene, the nurse can identify potential
hazards to staff and children. These findings allow the nurse and staff to enter the scene and safely
provide care to injured children and help decrease the risk of further injury.
A nurse in an ED is caring for a patient who is unconscious and requires emergency medical procedures.
The nurse is unable to locate members of the patient’s family to obtain consent. Which of the following
actions should the nurse take?
Answer: Proceed with provision for medical care.
When a patient is unable to give informed consent in an emergency, health care personnel can proceed
with necessary life-saving care because the law considers this implied consent.
A nurse is caring for a school-aged child who is taking valproic acid. The nurse should expect the
provider to order which of the following diagnostic tests?
Answer: Serum liver enzyme levels.
Valproic acid can cause hepatic toxicity. The nurse should expect the provider to prescribe lab tests to
assess the child’s liver function prior to and periodically during therapy.
A nurse manager is preparing to teach a group of newly licensed nurses about effective time management.
Which of the following steps of the time management process should the nurse manager include as the
priority?
Answer: Making a list of activities to complete.
According to evidence-based practice, planning is the most important step in managing time effectively.
The nurse manager should include making a list of activities to complete as the priority. Other planning
activities include setting goals, establishing priorities, and scheduling activities.
A nurse is caring for a client who has a pulmonary embolism. The patient is receiving heparin
viacontinuous IV infusion at 1200 units/hr and warfarin 5 mg PO daily. The morning lab values for the
patient are aPTT 98 seconds and INR 1. 8. Which of the following actions should the nurse take?
Answer: Withhold the heparin infusion.
The expected value for aPTT is 40 seconds. A therapeutic level of heparin increases the aPTT by a factor
of 1. 5-2, making the aPTT 60-80 seconds. An aPTT level of 98 is above the expected reference range,
indicating that the dosage should be reduced, or the infusion withheld until the aPTT returns to the
therapeutic range.
A nurse is providing teaching to a school-age child who has asthma about using an albuterol metereddose inhaler. Which of the following instructions should the nurse include?
Answer: Take the medication 15 mins before playing sports.
Take 5-20 min prior to exercise to promote bronchodilation. The meds effects begin immediately, peak in
30-60 min, and can last for up to 5 hr.
home health nurse is evaluating a school aged child who has cystic fibrosis. The nurse should initiate a
request for a high-frequency chest compression vest in response to which of the following parent
statements?
Answer: “My child has only a small amount of mucus after percussion therapy. ”
The nurse should recommend a high-frequency chest compression vest for a child who has inadequate
results from other airway clearance therapy techniques. Older children often require other techniques in
addition to percussion and postural drainage to achieve adequate mucus expectoration.
A nurse is planning care for a patient who is receiving chemotherapy and has neutropenia. Which of the
following interventions should the nurse include in the plan?
Answer: Avoid including raw fruits in the patient’s diet. This reduces the risk of bacterial infections.
A nurse is caring for a client who is in the fourth stage of labor and is receiving oxytocin viacontinuous
IV infusion. Which of the following assessments is the nurse’s priority?
Answer: Amount of vaginal bleeding.
The first action the nurse should take u sing the nursing process is assessing the amount of vaginal
bleeding. A patient who is in the fourth stage of labor is at risk for hemorrhage, so assessing the amount
of vaginal bleeding is the nurse’s priority.
A nurse is caring for a client who is in the resuscitation phase of burn injury. Which of the following
findings should the nurse expect?
Answer: Hyponatremia
The nurse should expect a decrease in sodium levels because sodium is drawn to the edematous burn
areas and lost through plasma leakage.
A nurse is teaching a patient who has a new prescription for total parenteral nutrition through a central
line. Which of the following information should the nurse include in the teaching?
Answer: “I will need to measure your weight daily. ”
The nurse should instruct the patient that daily w eight measurement is a necessary part of administering
nutrition through a central line to avoid fluid overload and monitor for adequate weight gain.
A nurse is assessing a patient who has bipolar disorder. Which of the following alterations in speech is the
patient using?
Answer: Flight of ideas.
Flight of ideas is an alteration in speech in which the speaker talks continuously with sudden, frequent
topic changes.
A home health nurse is caring for a group of older adult patients. The nurse should initiate a referral to the
Program of All-Inclusive Care for the Elderly (PACE) for which of the following patients?
Answer: A patient whose caregiver requests adult daycare services.
The nurse should initiate a referral for PACE for this patient because PACE provides adult day care
services along with in-home assessments and supportive services.
A nurse at a mental health clinic is caring for four patients. The nurse should recognize that which of the
following patients is using dissociation as a defense mechanism?
Answer: A patient who was abused as a child describes the abuse as if it happened to someone else.
The nurse should identify that this patient is using the defense mechanism of dissociation because they
are separating painful events from the conscious mind and describing the events as if they happened to
another person.
A nurse is caring for a client who has active pulmonary tuberculosis. Which of the following actions
should the nurse take?
Answer: Assign the patient to a private room with negative air pressure.
To control the spread of active TB, the nurse should assign the patient to a private room with negative air
pressure.
A nurse is providing teaching to a patient who is at 24 weeks of gestation and is scheduled for a3 hr oral
glucose tolerance test. Which of the following instructions should the nurse include in the teaching?
Answer: “You will need to fast the night before the test. ”
The nurse should instruct the patient that they will need to fast the night before the test to prevent
inaccurate test results.
A nurse is providing education to the parent of a school-age child who has asthma. Which of the
following statements by the parent indicates an understanding of the teaching?
Answer: “I will make sure my child receives a yearly influenza immunization. ”
Children who have asthma should be immunized and protected from infections. The nurse should educate
the parent to ensure the child receives a yearly influenza immunization.
A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following lab
tests should the nurse review prior to adjusting the patient’s heparin?
Answer: aPTT
Prior to adjusting the patient’s continuous heparin infusion, the nurse should review the patient’s activated
partial thromboplastin (aPTT). T he expected reference range for the aPTT is 40 secs. patients who are
receiving continuous heparin therapy should have an aPTT of 60-80 secs, which is 1. 5-2 times the
expected aPTT level. The nurse should increase or decrease the heparin infusion according to this value.
A nurse is assessing a patient who is taking propranolol. Which of the following findings should indicate
to the nurse that this patient is experiencing an adverse reaction to propranolol?
Answer: Wheezing
The nurse should recognize that wheezing can indicate the patient is experiencing an adverse reaction to
the med.
A patient is receiving IV fluids at 150 m L/hr. Which of the following findings indicates that The patient
is experiencing fluid overload?
Answer: Dyspnea
The nurse should recognize that dyspnea indicates the patient could be experiencing fluid overload. Fluid
overload can lead to the backup of fluid in the pulmonary system resulting in shortness of breath.
A nurse is assessing a patient whose partner recently died. The patient states, “I don’t know what to do
without my partner. Life is just not worth living. ” Which of the following responses should the nurse
make?
Answer: “You seem to be having a difficult time right now. ”
This statement makes an observation, which is a therapeutic response by the nurse. It encourages the
patient to express their thoughts and feelings.
A nurse must recommend patients for discharge in order to make room for several critically injured
patients from a local disaster. Which of the following patients should the nurse recommend discharge?
Answer: A patient who has cellulitis and is receiving oral antibiotics every 8 hr.
This patient can safely continue this treatment at home.
A nurse is performing an admission assessment on a patient who had a recent positive pregnancy test. The
first day of her last menstrual period (LMP) was May 8. According to Nagele’s rule, which of the
following dates should the nurse document as the patient’s estimated date of birth (EDB)?
Answer: February 15
Add 7 days to the first day of the patient’s LMP and then subtract 3 months.
A nurse is providing teaching about home care to the parents of a child who has autism spectrum disorder.
Which of the following instructions should the nurse include? Use a rewards system to modify the child’s
behavior.
Answer: Children who have autism spectrum disorder respond well to a reward system, which can
provide structure and expectations for behavior.
A nurse in a provider’s office is caring for an 18-month-old toddler who has a blood level of 3mcg/dL.
Which of the following actions should the nurse take?
Answer: Recommend rescreening in 1 year.
This level is within the expected reference range.
A nurse is caring for a client who has cancer and is deciding between two treatment plans. The patient
asks the nurse for assistance in making the decision. Which of the following responses should the nurse
make?
Answer: “Tell me more about your understanding of the options. ”
This is therapeutic because it is offering a general lead that facilitates communication between the nurse
and the patient and will help the nurse to explore the patient’s feelings about the treatment options.
A nurse is caring for a client who has a new prescription for clonidine. The nurse should inform the
patient that which of the following findings is an adverse effect of this med?
Answer: Dry mouth.
Clonidine is an indirect-acting antiadrenergic agent used for HTN, severe pain, and ADD. The nurse
should inform the patient that dry mouth, or xerostomia, is a common adverse effect of this med.
A nurse is creating a plan of care for a patient who has left-sided weakness following a stroke. Which of
the following interventions should the nurse include in the plan?
Answer: Support the patient’s left arm on a pillow while sitting.
This prevents the extremity from hanging freely because this can cause shoulder subluxation.
A nurse is caring for a client who has acute blood loss following a trauma. The patient refuses a blood
transfusion that might potentially save their life. Which of the following actions should the nurse take
first?
Answer: Explore the patient’s reasons for refusing the treatment.
This is assessment. The nurse should gather more data regarding the patient’s decision tore fuse the blood
transfusion.
A nurse is performing an abdominal assessment on a patient. Identify the sequence of actions the nurse
should take.
Answer: Inspection, auscultation, percussion, palpation
Inspect to assess skin integrity and symmetry. Auscultate. Percuss for tympany, dullness, absence or
flatness of resonance. Palpate for tenderness, pain, or the presence of a mass.
A nurse is providing teaching to the guardians of a newborn about measures to prevent sudden infant
death syndrome (SIDS). Which of the following guardian statements indicates an understanding of the
teaching?
Answer: “I will not allow anyone to smoke near my baby. ”
Research indicates a strong correlation between exposure to cigarette smoke and the occurrence of SIDS.
A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following
interventions should the nurse use to maintain surgical aseptic technique?
Answer: Maintain sterile objects with the line of vision.
Objects out of the line of vision are not considered sterile. Keep sterile items at least 1 inch (2. 5cm) away
from the border of a sterile drape. Hold gloved hands away from the body and above waist level to
prevent contamination.
A nurse is caring for a client who has a magnesium level of 2.7 mEq/L. Which of the following
interventions should the nurse plan to take?
Answer: Initiate continuous cardiac monitoring.
This patient is at risk for cardiac dysrhythmias and cardiac arrest.
A nurse is assessing a patient who is at 11 weeks of gestation and reports drinking ginger tea. Which of
the following findings indicates the patient’s use of ginger tea is effective?
Answer: The patient reports a decrease in episodes of nausea.
The patient can also use ginger ale and ginger snaps to alleviate nausea associated with pregnancy.
A nurse is caring for a client who has a deep vein thrombosis. Which of the following actions should the
nurse take?
Answer: Instruct the patient to elevate the affected extremity when sitting. Reduce edema and facilitate
venous return.
A nurse is preparing to replace a patient’s transdermal fentanyl patch after 72 hours of use. After the nurse
opens the packet containing the new patch, the patient declines to accept it. Which of the following
actions should the nurse take?
Answer: Ask another nurse to witness the disposal of the new patch.
Place the med in a secure receptacle, according to agency policy, when disposing of any unused portion
of a controlled substance.
A nurse is assessing a n older adult patient who has pneumonia. Which of the following findings should
the nurse expect?
Answer: Acute confusion.
Will have acute confusion, fatigue, lethargy, and anorexia.
A nurse is providing client teaching about the basal body temp method of birth control. Which of the
following information should the nurse include in the teaching?
Answer: “Your body temp might decrease slightly just prior to ovulation. ”
A decrease of 1° F commonly occurs immediately prior to ovulation.
A nurse manager in a long term facility is having difficulty with staffing for weekend shifts and is
planning to implement some changes to the scheduling procedure. Which of the following actions should
the nurse manager take first?
Answer: Form a committee of staff members to investigate current staffing issues.
Assess the staffing issue. The first stage of change is the “unfreezing stage, ” in which information is
gathered about the problem. The first action the nurse manager should take is to form a committee to
investigate the problem.
A nurse is preparing to administer an IM injection to a patient who is obese. Which of the following
actions should the nurse plan to take?
Answer: Use the ventrogluteal site.
It has a thick area of muscle and contains no large nerves or blood vessels.
A hospice nurse is consulting with a patient and her family about receiving home services. Which of the
following statements should the nurse identify as an indication that the family understands home hospice
care?
Answer: “We can expect the hospice nurse to provide support for us after our mother’s death. ”Hospice
care includes bereavement services after a family member’s death.
A nurse is caring for a client who is receiving positive end-expiratory pressure (PEEP) via mechanical
ventilation. The nurse should monitor the patient for which of the following adverse effects of PEEP?
Answer: Tension pneumothorax
The nurse should identify that tension pneumothorax is a possible adverse effect of PEEP.
The nurse should monitor the patient’s lung sounds hourly for indications of a tension pneumothorax,
such as tracheal deviation, absent breath sounds, and distended neck veins.
A nurse manager is reviewing the patient’s rights with the nurses on the unit. The nurse manager should
tell the nurses that informed consent promotes which of the following ethical principles? Autonomy
Answer: Autonomy refers to a patient’s ability to make their own decisions about treatment. Informed
consent promotes autonomy by providing patients with complete information about treatment.
A nurse preceptor is evaluating the performance of a newly licensed nurse. Which of the following
actions by the newly licensed nurse requires intervention by the preceptor? Starts a task then determine
what supplies are needed.
Answer: The preceptor should intervene and instruct the newly licensed nurse to gather supplies before
performing patient tasks to practice effective time management.
A nurse manager is preparing an educational session about advocacy for a group of nurses. The nurse
manager should include which of the following information in the teaching?
Answer: Advocacy is a leadership role that helps others to self-actualize.
The nurse manager should teach that advocacy is a leadership role that can help others to grow personally
and professionally through self-actualization.
A nurse is admitting a patient who has pneumonia. The nurse should initiate which of the following
isolation precautions for the patient?
Answer: Droplet
The nurse should initiate droplet precautions for this patient by placing the patient in a private room and
wearing a surgical mask when caring for the patient. Pneumonia is transmitted by droplet particles.
A nurse has just received change of shift report on four patients. Which of the following patients should
the nurse assess first?
Answer: A patient who is postoperative with abdominal distention and no bowel sounds.
Using the acute vs chronic approach to patient care, the nurse should first assess the patient who is
postoperative with abdominal distention and no bowel sounds because these manifestations are an
indication of paralytic ileus.
During a change of shift report, a night shift nurse informs the day shift nurse that a newly admitted
patient was disoriented and combative during the night. Which of the following actions should the day
shift nurse take?
Answer: Move the patient to a room near the nurses’ station.
The day shift nurse should move the patient to a room near the nurses’ station to enhance the staff’s
ability to keep the patient under frequent observation.
A nurse is reviewing the laboratory results of a toddler who has hemophilia A. Which of the aPTT values
should the nurse expect?
Answer: 45 seconds
This value is above the expected reference range of 30-40 seconds and indicates a risk for spontaneous
bleeding, which is a manifestation of hemophilia A.
A nurse is planning care for a patient who has rheumatoid arthritis. Which of the following interventions
should the nurse include in the plan?
Answer: Increase the patient’s dietary iron intake.
patients who have rheumatoid arthritis require foods high in protein, vitamins, and iron to promote tissue
repair. The nurse should encourage the patient to increase their intake of dietary iron.
A nurse is an outpatient mental health facility is assessing a child who has autism spectrum disorder.
Which of the following manifestations should the nurse expect?
Answer: Strict adherence to routines
The nurse should identify that a child who has autism spectrum disorder can exhibit strict adherence to
routines or rituals, a fixation to specific objects, and resistance to change.
A nurse is caring for a client who had a stroke 6 hr ago. Which of the following interventions should the
nurse implement to reduce the risk of increased intracranial pressure (ICP)?
Answer: Place the patient in a quiet environment.
The nurse should keep the patient’s environment quiet to minimize the risk of increasing ICP.
