Preview Extract
NEXT GENERATION RN ATI FUNDAMENTALS OF NURSING
PROCTORED EXAM 2023 WITH NGN
10. A nurse is assessing an adult client who has been immobile for the past 3 week. The nurse
should identify that which of the following findings requires further intervention?
A. erythema on pressure points
B. lower-extremity pulse strength on 2+
C. fluid intake of 3,000 mL per day
D. a bowel movement every other day
Answer: Erythema on pressure points
Erythema on pressure points requires prompt relief of pressure and additional measures to
protect the skin from further breakdown.
11. A nurse is caring for a client who requires a 24-hour urine collection. which of the
following statement by the client indicates an understanding of the teaching?
A. "I had a bowel movement, but I was able to save the urine."
B. "I have a specimen in the bathroom from about 30 minutes ago."
C. "I flushes what I urinated at 7 am and have saved all urine since."
D. "I drink a lot, so I will fill up the bottle and complete the txt quickly."
Answer: "I flushed what I urinated at 7:00 a.m. and have saved all urine since."
For a 24-hr urine collection, the client should discard the first voiding and save all
subsequent voiding.
12. A nurse is caring for a client who has herpes zoster and asks the runs about the use of
complementary and alternative therapies for pain control. the nurse should inform the client
that his condition is a contraindication for which of the following therapies?
A. Biofeedback
B. aloe
C. feverfew
D. acupuncture
Answer: Acupuncture
The nurse should inform the client that the use of acupuncture is contraindicated for a client
who has herpes zoster, or any skin infection, to prevent an open portal on the skin's surface,
which could increase the risk of further infection.
13. A nurse is preparing to transfer a client who has right-sided weakness from the bed to a
chair. In what order should the nurse take the following actions to assist the client?
1. ask the client is he can bear weight
2. use the stand-pivot technique to move the client to the chair
3. position the chair on the left side of the bed
4. have the client sit and dangle his feet at the bedside
Answer:
1. ask the client is he can bear weight
3. position the chair on the left side of the bed
4. have the client sit and dangle his feet at the bedside
2. use the stand-pivot technique to move the client to the chair
14. A nurse is preparing to administer an injection of an opioid medication to a client. The
nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions
should the nurse take?
A. ask another nurse to observe the medication wastage
B. notify the pharmacy when eating the medication
C. lock the remaining medication in the controlled substance cabinet
D. dispose of the vial with the remaining medication in a sharps container
Answer: Ask another nurse to observe the medication wastage.
A second nurse must witness the disposal of any portion of a dose of a controlled substance.
15. A nurse is preparing a her paring infusion for a client who was hospitalized with deepvein thrombosis. The orders read: 25,000 units of heparin in 250mL of 0.9% sodium chloride
to infuse at 800 units/hr. at what rate should the nurse set the infusion pump? (round to the
nearest whole number)
Answer: 8mL/hr
The calculation ensures that the prescribed amount of heparin (800 units/hr) is administered
correctly. By setting the pump to 8 mL/hr, the nurse ensures that the patient receives the
correct dosage of heparin as per the doctor's orders.
16. nurse is caring for a client who has a prescription for 5 units of regular insulin and 10
units of NPH insulin to mix together and administer subcutaneously. Determine the correct
order of steps for this procedure.
1. inject 5 units of air into the bottle of regular insulin
2. withdraw the correct dose of NPH insulin from the bottle
3. inject 10 units of air into the bottle of NPH insulin
4. withdraw the correct dose of regular insulin from the bottle
Answer:
3. inject 10 units of air into the bottle of NPH insulin
1. inject 5 units of air into the bottle of regular insulin
4. withdraw the correct dose of regular insulin from the bottle
2. withdraw the correct dose of NPH insulin from the bottle
17. A nurse is caring for a client who is postoperative and refused to use an incentive
spirometer following major abdominal surgery. Which of the following is the nurse's priority
action?
A. request that a respiratory therapist discuss the technique for incentive spirometer
B. determine the reasons why the client is refusing to use the onetime spirometer
C. document the client's refusal to participate in health restorative activities
D. administer a pain medication to the client
Answer: Determine the reasons why the client is refusing to use the incentive spirometer.
The first action the nurse should take when using the nursing process is to assess the client;
therefore, the priority action is for the nurse to determine why the client is refusing the
treatment.
18. A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by
mouth every day." which of the following components of the prescription should the runs
question?
A. the medication
B. the route
C. the dose
D. the frequency
Answer: The dose
The dose is not complete. The number 0.25 should be followed by a unit of measurement,
such as mg, to clarify the amount the nurse should administer.
19. A nurse is caring for a client who has limited mobility in his lower extremities. Which of
the following actions should the nurse take to prevent skin breakdown?
A. place the client in high-flowers position
B. increase the client's intake of carbohydrates
C. massage the reddened areas with unscented lotion
D. have the client use a trapeze bar when changing positions
Answer: Have the client use a trapeze bar when changing position.
By using a trapeze bar to assist with repositioning and transferring, the client avoids the
friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for
pressure ulcer development.
20. nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine
IV STAT for a client who has myxoedema coma. How should the nurse transcribe the dosage
of this medication on the client's medical record?
A. .3 mg B.
B. 0.3 mg
C. 0.30 mg
D. 3/10 mg
Answer: 0.3 mg
The use and placement of a decimal point can cause a medication error. A zero should
precede a decimal point (0.3 mg), but should not follow a decimal point unless a whole
number follows the zero, as in 2.05 mg.
21. A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the
following filings at the IV site should the nurse identify as infiltration?
A. purulent exudate
B. warmth
C. skin blanching
D. bleeding
Answer: Skin blanching
Edema, and coolness at the IV site indicate infiltration.
22. A nurse is preparing to administer multiple medications to a client who has an enteral
feeding tube. Which of the following actions should the nurse plan to take?
A. dissolve each medication in 5 mL of sterile water
B. draw up medication together in the syringe
C. push the syringe plunger gently when feeling resistance
D. flush the tube with 15 mL of sterile water
Answer: Flush the tube with 15 mL of sterile water.
The nurse should flush the feeding tube with 15 to 30 mL of sterile water before
administration and between each medication. The nurse should flush the feeding tube with 30
to 60 mL of sterile water following the administration of the last medication.
23. A nurse is planning an education session for an older adult client who has just learned that
she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to
use with this client?
A. allow extra time for the client to respond to questions
B. expect the client to have difficulty understanding the information
C. avoid references to the lento's past experiences
D. keeping the learning session private and one-on-one
Answer: Allow extra time for the client to respond to questions.
Older adult clients often process information at a slower rate than younger clients; therefore,
the nurse should plan for extra time to allow the client to ask questions and absorb the
information.
24. nurse is evaluating a client's use of a cane. Which of the following actions should the
nurse identify as an indication of correct use?
A. the top of the cane is parallel to the client's waist
B. when walking, the client move the cane 46 cm (18 in) forward
C. the client holds the cane on the stronger side of her body
D. the client moves her stronger limb forward with the cane
Answer: The client holds the cane on the stronger side of her body.
The client should hold the cane on the stronger side of her body to increase support and
maintain alignment.
25. A nurse is caring for a client who has had his diet prescription changed to a mechanical
soft diet. Which of the following food items should the nurse remove from the client's
breakfast tray?
A. smoothie
B. sliced banana
C. pancakes
D. sunny side up (fired) eggs
Answer: Sunny side up (fired) eggs
Evidence-based practice indicates the nurse should remove fried eggs from the client’s tray.
Fried eggs are not a part of a mechanical soft diet. Eggs that are poached or scrambled are
an acceptable replacement for this item.
26. A nurse is caring for a client who asks about the purpose of advance directives. Which of
the following statements should the nurse make?
A. "they allow the court to overrule an adult client's refusal of medical treatment."
B. "they indicate the form of treatment a client is willing to accept in the event of a serious
illness."
C. "the permit a client to withhold medical information from heath care personnel."
D. "they allow heath care personnel in the emergency department to stabilize a client's
condition."
Answer: "They indicate the form of treatment a client is willing to accept in the event of a
serious illness."
Advance directives include a living will, which permits the client to direct treatment in the
event of a terminal illness.
27. A nurse is assessing a client who has been on bed rest for the past month. Which of the
following findings should the nurse identify as an indication that the client has developed
thrombophlebitis?
A. bladder distention
B. decreased blood pressure
C. calf swelling
D. diminished bowel sounds
Answer: Calf swelling
Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a
common complication of immobility.
28. nurse is caring for a client who report pain. when documenting the quality of the client's
pain on an initial pain assessment, the nurse should record which of the following client
statements?
A. "I'm having mild pain."
B. "the pain is like a dull ache in my stomach."
C. "I notice that the pain gets worse after I eat."
D. "the pain makes me feel nauseous."
Answer: "The pain is like a dull ache in my stomach."
The client is describing the quality of the pain, which is how the pain feels in her own words.
29. A nurse is administering an otc medication to an older adult client. Which of the
following actions should the nurse take to ensure that the medication reaches the inner ear?
A. press gently on the tarsus of the client's ear
B. pack a small piece of cotton deep into the cent's ear canal
C. move the client's auricle down and back toward her head
D. tilt the client's head backward for 5 min
Answer: Press gently on the tragus of the client's ear.
Pressing gently on the tragus of the ear will help the medication get into the inner ear.
30. A nurse in a long-term care facility is planning to perform hygiene care for anew resident.
Which of the following assessment questions is the nurse's priority before beginning this
procedure?
A. "when do you usually bathe, in the morning or evening?"
B. "do you prefer a bath or a shower?"
C. "at what temperature do you prefer your bath water?"
D. "are you able to help with you hygiene care?"
Answer: "Are you able to help with your hygiene care?"
The greatest risk to the client's safety is an injury resulting from an overestimation of the
client's ability to help with hygiene care; therefore, the nurse’s priority is to assess the client's
ability to assist with her hygiene care.
31. A charge nurse is discussing the responsibility of nurses caring for clients who have a
clostridium difficile infection. Which of the following information should the nurse include in
the teaching?
A. assign the client to a room with a negative air-flow system
B. use alcohol-based hand sanitizer when leaving he client's room
C. clean contaminated surfaces in the client's room with a phone solution
D. have family members wear gown and gloves when visiting
Answer: Have family members wear a gown and gloves when visiting.
Nurses are responsible for ensuring that family members wear a gown and gloves to prevent
the transmission of Clostridium difficile spores. Caregivers must also wear gowns and gloves.
32. A nurse is assessing an older adult client's risk for falls. which of the following
assessments would the nurse use to identify the cent's safety needs? (Select all that apply).
A. lacrimal apparatus
B. pupil clarity
C. appearance of bulbul conjuctivae
D. visual fields
E. visual acuity
Answer: B. pupil clarity
D. visual fields
E. visual acuity
33. A nurse is caring for a client who is expressing anger over his diagnosis of colorectal
cancer. Which of the following actions should the nurse take?
A. discuss the risk factors for colon cancer
B. focus teaching on what the client will need to do in the future to manage his illness
C. provide the client with written information about the phases of loss and grief
D. reassure the client that this is an expected response to grief
Answer: Reassure the client that this is an expected response to grief.
During the anger stage of the client's psychosocial adaptation to illness, the nurse should
support the client and ensure him that this is an expected reaction to a cancer diagnosis.
34. A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of
the following actions should the nurse plan to take?
A. insert the other at a 45º angle
B. place the client's arm in a dependent position
C. shave excess hair from the insertion site
D. initiative IV therapy in the veins of the hand
Answer: place the client's arm in a dependent position
The nurse should place the client's arm in a dependent position because the veins will dilate
due to gravity.
35. A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair to
prevent self-injury, which of the following actions should the nurse take when lifting this
object?
A. bend at the waist
B. keep his feet close together
C. use his back muscles for lifting
D. stand close to the banner when lifting it
Answer: Stand close to the cabinet when lifting it.
This action keeps the cabinet close to the nurse's center of gravity and decreases back strain
from horizontal reaching.
36. A nurse is providing care to four clients. Which of the following situations requires the
nurse to complete an incident report?
A. a nurse tied a client's restraints straps to the moveable part of the bedframe
B. an assuétude personnel placed a surgical mask on a client who has TB before transporting
her to radiology
C. a nurse administer a medication to a client 30 min before the dose is due
D. a client who has an IV infusion pump receives an additional 250 mL of IV fluid
Answer: A client who has an IV infusion pump receives an additional 250 mL of IV fluid.
The nurse should complete an incident report if an IV infusion pump malfunctions to assist in
compiling information for risk management to determine actions to take to prevent further
similar incidents.
37. A nurse manager is preparing to review medication documentation with a group of newly
Licensed nurses. Which of the following statements should the nurse manger plan to include
in the teaching?
A. "use the complete name of the medication magnesium sulphate."
B. "delete the space between the numerical dose and the unit of measure."
C. "write the letter U when noting the dosage of insulin."
D. "use the abbreviation SC when indicating an injection."
Answer: "Use the complete name of the medication magnesium sulphate."
The Institute for Safe Medication Practices designates that nurses and providers write the
complete medication name magnesium sulphate when documenting medications to avoid any
misinterpretation of MgSO4 as MSO4, which means morphine sulphate
38. A nurse in a surgical suite notes documentation on a client's medical record that he has a
latex allergy. in preparation for the client's procedure, which of the following precautions
should the nurse take?
A. ensure sterilization of non-disposable items with ethylene oxide
B. wrap monitoring cords with stockinette and tape them in place
C. cleanse latex pots on IV tubing with chlorohexidine before injection medication
D. wear hypoallergenic latex gloves that contain powder
Answer: Wrap monitoring cords with stockinette and tape them in place.
Many monitoring devices and cords contain latex. The nurse should prevent any contact of
these cords and devices with the client's skin by covering them with a nonlatex barrier
material, such as stockinette, and using nonlatex tape to secure them.
39. A nurse is caring for a client who requires an NG tube for stomach decompression. Which
of the following actions should the nurse take when inserting the NG tube?
A. position the client with the head of the bed elevated to 30º prior to insertion of the
NG tube
B. remove the NG tube if the client begins to gag of choke
C. apply suction to the NG tube prior to insertion
D. have the client take sips of water to promote insertion of the NG tube into the esophagus
Answer: Have the client take sips of water to promote insertion of the NG tube into the
esophagus.
Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis
over the trachea and prevent the tube's passage into the trachea.
40. A nurse is admitting a client who has an abdominal wound with a large amount of
purulent drainage. Which of the following types of transition precautions hold the nurse
initiate?
A. protective environment
B. airborne precautions
C. droplet precautions
D. contact precautions
Answer: Contact precautions
Major wound infections require contact precautions, which mean the nurse should admit the
client to a private room. All caregivers should wear a gown and gloves during direct contact
with this client.
41. A nurse is caring for a client who has a prescription for wound irrigation. Which of the
following actions should the nurse take?
A. wear sterile gloves when removing the old dressing
B. warm the irrigation solution of 40.5ºc (105ºF)
C. cleanse the wound from the center outward
D. use a 20 mL syringe to irrigate the wound
Answer: Cleanse the wound from the center outward.
The nurse should clean the wound from the center outward to prevent introduction of microorganisms from the outer skin surface.
42. A nurse is caring for a client who requires bed rest and has a prescription for anti embolic
stocking. Which of the following actions should the nurse take?
A. apply the stockings so the creases are on the front of the leg
B. apply the stockings while the client's legs are in a dependent position
C. remove the stockings at least once per shift
D. remove the stockings while the client is sitting in a reclining chair
Answer: Remove the stockings at least once per shift.
The nurse should remove the stocking once per shift to check the client's circulation and skin
integrity.
43. A nurse is caring for a client who has an NG tube and is receiving intermittent feedings
through an open system. Which of the following actions should the nurse take first?
A. rinse the feeding bag with water between feedings
B. tell the client to keep the head of the bed elevated at least 30º
C. make sure the enteral formula is at room temperature
D. wipe the top of the formula can with alcohol
Answer: Tell the client to keep the head of the bed elevated at least 30°.
The first action the nurse should take when using the airway, breathing, circulation approach
to client care is to prevent aspiration of the enteral formula; therefore, the priority
intervention is to keep the head of the bed elevated at least 30° to prevent reflux of the
formula backward into the esophagus.
44. A nurse is caring for a client who has tuberculosis. Which of the following actions should
the nurse take? (Select all that apply)
A. place the client in a room with negative pressure airflow
B. wear gloves the assisting the client with oral care
C. limit each visitor to 2 hour increments
D. wear a surgical mask when providing client care
E. use antimicrobial sanitizer for hand hygiene
Answer: A. place the client in a room with negative pressure airflow
B. wear gloves the assisting the client with oral care
E. use antimicrobial sanitizer for hand hygiene
45. A nurse is responding to a call light and finds a client lying on the bathroom floor. Which
of the following actions should the nurse take first?
A. check the client for injuries
B. move hazardous objects away from the client
C. notify the provider
D. ask the client to describe how she felt prior to the fall
Answer: Check the client for injuries.
The first action the nurse should take when using the nursing process is to assess the client
for injuries.
46. A nurse is talking with the partner of an older adult male client who has dementia. The
client's partner expresses frustration about finding time to manage household responsibilities
while caring for his partner. The nurse should identify that he is going through which of the
following types of role-performing stress?
A. role ambiguity
B. sick role
C. role overload
D. role conflict
Answer: Role overload
The partner's expression of frustration is an example of role overload, which refers to having
more responsibilities within a role than one person can perform.
47. A nurse is administering IV fluid to an older adult client. The nurse should perform which
priority assessment to monitor for adverse effects?
A. auscultate lung sounds
B. measure urine output
C. monitor blood pressure readings
D. monitor serum electrolyte levels
Answer: Auscultate lung sounds.
The priority assessment the nurse should make when using the airway, breathing, circulation
approach to client care is auscultating lung sounds to monitor for fluid-volume excess, a
complication of IV therapy. Manifestations of fluid volume excess include moist crackles
heard in lung fields, dyspnea, and shortness of breath.
48. A nurse is performing a peripheral vascular assessment for a client. When placing the bell
on the stethoscope on the client's neck, she heads the following sound: audible vascular sound
associated with turbulent blood flow. This sound indicates which of the following?
A. narrowed arterial lumen
B. distended jugular veins
C. impaired ventricular contraction
D. asynchronous closure of the aortic and pulmonic valve
Answer: Narrowed arterial lumen
Arterial bruits are blowing sounds resulting from blood flowing through occluded or
narrowed arteries.
49. A nurse is completing an admission assessment for a client who reports vomiting and
diarrhoea for the past 3 days. Which of the following assessment findings should the nurse
expect?
A. neck vein distention
B. urine specific gravity 1.010
C. rapid heart rate
D. blood pressure 144/82 mm Hg
Answer: Rapid heart rate
Tachycardia indicates fluid-volume deficit, which is an expected finding for a client who has
had vomiting and diarrhoea for 3 days.
50. A nurse is caring for a client who has terminal live cancer. Which of the following
statements should the nurse identify as an indication that the client is experiencing spiritual
distress?
A. "what could I have done to deserve this illness?"
B. "I blame medical science for not curing me."
C. "where is my daughter at a time like this?"
D. "will I ever begin to feel in charge of my life again?"
Answer: "What could I have done to deserve this illness?"
The client's terminal illness might prompt him to review his life and question its meaning. A
manifestation of the client's spiritual distress is asking why this illness is happening to him.
51. A nurse is using an open irrigation technique to irrigate a client's indwelling urinary
catheter. Which of the following actions should the nurse take?
A. place the client in a side-lying position
B. instil 15 mL of irrigation fluid into the catheter with each flush
C. subtract the amount of irritant used from the client's urine output
D. perform the irrigation using a 20 mL syringe
Answer: Subtract the amount of irrigant used from the client's urine output.
The nurse should calculate the fluid used for irrigation and subtract it from the client’s total
urinary output.
52. A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The
client's partner wants the client to have the blood transfusion. Which of the following actions
should the nurse take?
A. ask the client to consider a direct donation
B. withhold the blood transfusion
C. request a consolation with the ethics committee
D. ask the client's family to intervene
Answer: Withhold the blood transfusion.
The principle of autonomy ensures that a client who is competent has the right to refuse
treatment.
53. A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings
should the nurse report to the provider?
A. BUN 15 mg/dL
B. Creatinine 0.8 mg/dL
C. Sodium 143 mg/dL
D. Potassium 5.4 mg/dL
Answer: Potassium 5.4 mEq/L
The value is above the expected reference range and the nurse should report this finding. This
client is at risk for dysrhythmias.
54. A nurse is admitting a client who has influenza. Which of the following types of
transmission precautions hold the nurse initiate?
A. Airborne
B. droplet
C. contact
D. protective environment
Answer: Droplet
Droplet precautions are a requirement for clients who have infections that spread via droplet
nuclei that are larger than 5 microns in diameter, including influenza, rubella, meningococcal
pneumonia, and streptococcal pharyngitis.
55. A nurse is caring for a client who is terminally ill. which of the following statements
should the nurse identify as an indication that the client's family member is coping effectively
with the situation?
A. "we are not worried. We still have hope that everything will be ok."
B. "this is a difficult time, but we are helping each other through this."
C. "after he comes home, we can plan out family reunion."
D. "we don't need to talk about funeral arraignments at this time."
Answer: "This is a difficult time, but we are helping each other through this."
An effective coping strategy is talking with others in the family and supporting each other.
This statement displays effective coping skills because the family issuing social supports to
assist them throughout the grief process.
56. A nurse is reviewing practice guidelines with a group of newly licensed nurses. which of
the following interventions should the nurse include that is within the RN scope of practice?
A. insert an implanted port
B. close a laceration with sutures
C. place an endotracheal tube
D. initiate an enteral feeding though a gastrostomy tube
Answer: Initiate an enteral feeding through a gastrostomy tube.
It is within the RN scope of practice for nurses to initiate enteral feedings through
nasoenteric, gastrostomy, and jejunostomy tubes.
57. A nurse manager is overseeing the care on a unit. Which of the following should the nurse
manager identify as a violation of HIPAA guidelines?
A. a nurse who is caring for a client reviews the client's medical chart with the nursing
student who is working with the nurse
B. a nurse asks a nurse from another unit to assist with her documentation
C. a nurse who is caring for a client returns a call to the client's durable power of attorney for
health care designee to discuss the client's care
D. a nurse discusses a client's status with the physical therapies that is caring for the client's
bedside
Answer: A nurse asks a nurse from another unit to assist with her documentation.
Only health care professionals directly caring for a client may access medical information;
therefore, this is a violation of HIPAA guidelines.
58. A nurse is reviewing protocol in preparation for suctioning secretions from client who has
a new tracheostomy. Which of the following actions should the nurse plan to take?
A. use a resuscitation bag with 80% oxygen prior to the procedure
B. select a suction catheter that is half of the size of the lumen
C. place the end of the function catheter in water-soluble lubricant
D. adjust the wall suction apparatus to a pressure of 170 mm Hg
Answer: Select a suction catheter that is half the size of the lumen.
The nurse should select a suction catheter that is half the size of the lumen to prevent
hypoxemia and trauma to the mucosa.
59. A nurse is performing a Romberg's test during the physical assessment of a client. Which
of the following techniques should the nurse use?
A. touch the face with a cotton ball
B. apply a vibrating tuning fork to the clients forehead
C. have the client stand with her arms at her side and her feet together
D. perform direct percussion over the area of the kidneys
Answer: Have the client stand with her arms at her side and her feet together.
Romberg's test helps identify alterations in balance. The nurse should have the client stand
with her arms at her sides and her feet together to observe her for swaying and a loss of
balance.
60. A nurse is preparing a change-of-shift report. Which of the following tools or documents
should the nurse use to communicate continuity of care?
A. critical pathway
B. SBAR
C. transfer report
D. medication administration record (MAR)
Answer: Situation, background, assessment, and recommendation (SBAR)
SBAR is a communication tool used to relate a client's status during a change-of-shift report.
61. A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and
has fluid-volume deficit. Which of the following changes should the nurse identify as an
indication that the treatment was successful?
A. Increase in hematocrit
B. Increase in respiratory rate
C. Decrease in heart rate
D. Decrease in capillary refill time
Answer: Decrease in heart rate
Fluid-volume deficit causes tachycardia. With correction of the imbalance, the heart rate
should return to the expected range.
63. A nurse working in the emergency department is witnessing the signing of informed
consent forms for the treatment of multiple clients during her shift. Which of the following
individuals' signatures may the nurse legally witness? (Select all that apply.)
A. A teacher who brings in a 7-year-old student
B. A 16-year-old client who is married
C. A 27-year-old client who has schizophrenia
D. An adoptive parent who brings in his 8-year-old son
E. A 17-year-old mother who brings in her toddler
Answer: A 16-year-old client who is married
A 27-year-old client who has schizophrenia
An adoptive parent who brings in his 8-year-old son
A 17-year-old mother who brings in her toddler
A 16-year-old client who is married is correct. A minor who is married is emancipated and
can give consent for his own treatment.
A 27-year-old client who has schizophrenia is correct. An adult client who requires
psychiatric care can give consent for her own care unless the court has determined the client
to be incompetent.
An adoptive parent who brings in his 8-year-old son is correct. The adoptive parent of a child
is a parent and legal guardian and can sign to give consent for the child's care.
A 17-year-old mother who brings in her toddler is correct. A custodial parent who is a minor
can legally give consent for the medical treatment of her child.
64. A nurse is caring for a client who has a respiratory infection. Which of the following
techniques should the nurse use when performing nasotracheal suctioning for the client?
A. Insert the suction catheter while the client is swallowing.
B. Apply intermittent suction when withdrawing the catheter.
C. Place the catheter in a location that is clean and dry for later use.
D. Hold the suction catheter with her clean, nondominant hand.
Answer: Apply intermittent suction when withdrawing the catheter.
The nurse should apply intermittent suction during the withdrawal of the catheter to prevent
injury to the mucosa. Suctioning continuously for more than 10 seconds can cause
cardiopulmonary compromise.
65. A nurse is teaching a client about dietary management of hypercholesterolemia. Which of
the following foods should the nurse suggest that the client add to his diet?
A. Beef liver
B. Shellfish
C. Egg yolks
D. Avocados
Answer: Avocados
Avocados contain no cholesterol. Plant foods contain no cholesterol; foods from animals
contain cholesterol.
66. A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a
chair. After securing a safe environment, which of the following actions should the nurse take
next?
A. Rock the client up to a standing position.
B. Pivot on the foot that is the farthest from the chair.
C. Assess the client for orthostatic hypotension.
D. Apply a gait belt to the client.
Answer: Assess the client for orthostatic hypotension.
The first action the nurse should take using the nursing process is to assess the client. The
nurse should determine the client's risk for falling or fainting during the transfer by assisting
her to sit and dangle her feet on the side of the bed. The nurse should assess her for dizziness
and a significant drop in blood pressure before assisting her to stand and transfer into the
chair.
67. A nurse is caring for a group of clients. Which of the following actions should the nurse
take to prevent the spread of infection?
A. Carry a client's soiled linens out of the room in a mesh linen bag.
B. Place a client who has tuberculosis in a room with negative-pressure airflow.
C. Provide disposable plates and utensils for a client who is HIV-positive.
D. Dispose of a client's blood-saturated dressing in a trash bag inside a second trash bag.
Answer: Place a client who has tuberculosis in a room with negative-pressure airflow.
A client who has tuberculosis requires airborne precautions, which include placing the client
in a room that has negative-pressure airflow to reduce the risk of infection transmission.
68. A nurse is caring for a client who does not speak the same language as the nurse. When
working with the client through an interpreter, which of the following actions should the
nurse take?
A. Talk directly to the client, instead of the interpreter, when speaking.
B. Use a family member as the client's interpreter.
C. Make sure that the interpreter has a college degree.
D. Avoid asking the client personal questions through the interpreter.
Answer: Talk directly to the client, instead of the interpreter, when speaking.
When using an interpreter, the nurse should speak directly to the client and observe the client
when the interpreter is translating.
69. A nurse is caring for a client who has an indwelling urinary catheter. Which of the
following assessment findings indicates that the catheter requires irrigation?
A. Urine has an unusual Odor.
B Urine specific gravity is 1.035.
C Bladder scan shows 525 mL of urine.
D Urine is positive for ketones.
Answer: Bladder scan shows 525 mL of urine.
A. client who has an indwelling urinary catheter should have continuous urine flow without
an accumulation of urine in the bladder; therefore, the nurse should irrigate the catheter to
resolve a blockage.
70. A nurse is caring for a client who has diarrhoea due to shigella. Which of the following
precautions should the nurse take?
A. Have the client wear a mask when receiving visitors.
B. Wash her hands before and after contact with the client.
C. Assign the client to a room with negative-pressure airflow exchange.
D. Instruct all visitors to limit their time with the client.
Answer: Wash her hands before and after contact with the client.
Shigella requires the nurse to perform contact precautions to prevent the transmission of the
bacteria. The nurse should also use standard precautions, which require the nurse to perform
hand hygiene before and after direct contact with every client, regardless of their diagnosis.
71. A nurse on a medical unit is preparing to discharge a client to home. Which of the
following actions should the nurse take as part of the medication reconciliation process?
A. Seal unused hospital medications in a plastic bag.
B. Evaluate the client's ability to self-administer medications.
C. Report an identified discrepancy to The Joint Commission.
D. Compare prescriptions with medications the client received during hospitalization.
Answer: Compare prescriptions with medications the client received during hospitalization.
When performing medication reconciliation, the nurse should create a current, accurate list
of every medication the client is or should be taking. Part of the process is comparing the
medications the client received at the facility with those the provider has prescribed for the
client to take after discharge.
72. A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid
therapy. Which of the following interventions should the nurse implement to prevent
infection?
A. Thread the IV catheter so that the hub rests at the insertion site.
B. Shave excess hair from around the insertion site.
C. Cleanse the site with hydrogen peroxide before IV catheter insertion.
D. Palpate the site carefully just before inserting the IV catheter.
Answer: Thread the IV catheter so that the hub rests at the insertion site.
Inserting the catheter up to the hub reduces the risk of contamination along the length of the
catheter.
73. A nurse is caring for a client who needs to maintain a positive nitrogen balance for wound
healing. Which of the following food items should the nurse recommend as a good source of
complete protein?
A. Oat cereal
B. Refried beans
C. Peanut butter
D. Cheddar cheese
Answer: Cheddar cheese
Complete proteins contain enough of all nine of the essential amino acids that help maintain
and promote nitrogen balance. Cheese, poultry, and fish are examples of foods that are good
sources of complete protein.
74. A nurse is providing discharge teaching to a client who has a new prescription for a home
oxygen concentrator. Which of the following instructions should the nurse provide to the
client and his family? (Select all that apply.)
A. Check the cord routinely for frays or tearing.
B. Keep the unit at least 4 feet away from a gas stove.
C. Consider purchasing a generator for power backup.
D. Observe for signs of hypoxia.
E. Select synthetic clothing and bedding.
Answer: Check the cord routinely for frays or tearing
Consider purchasing a generator for power backup.
Observe for signs of hypoxia.
Check the cord routinely for frays or tearing is correct.
Oxygen concentrators require electrical power. Safe use of this delivery system includes
assessing the electrical function of the device; therefore, the nurse should instruct the client
to routinely check the condition of the cord.
Consider purchasing a generator for power backup is correct. Loss of electricity prevents the
oxygen concentrator from functioning and could deprive the client of the oxygen he needs.
The nurse should also instruct the family to explore getting the client on their municipality's
priority list for restoring power after an outage occurs.
Observe for signs of hypoxia is correct. The nurse should instruct the family to observe for
and report signs of hypoxia, such as anxiety, worsening fatigue, dizziness, rapid pulse and
respirations, pallor, and cyanosis. Even with supplemental oxygen, the client's status can
worsen, and he can develop hypoxia.
75. A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125
mL/hr. When the nurse performs the initial assessment, he notes that the client has received
only 80 mL over the last 2 hr. Which of the following actions should the nurse take first?
A. Reposition the client.
B. Document the client's IV intake in the medical record.
C. Request a new IV fluid prescription.
D Check the IV tubing for obstruction.
Answer: Check the IV tubing for obstruction.
The first action the nurse should take using the nursing process is to assess the client. By
checking the IV tubing for obstruction, the nurse might be able to facilitate the flow of fluid
through the tubing. This could re-establish the infusion rate the provider prescribed.
76. A nurse is planning care for a client who has fluid overload. Which of the following
actions should the nurse plan to take first?
A. Reduce dietary sodium
B. Administer a loop diuretic
C. Evaluate electrolytes
D. Restrict intake of oral fluids
Answer: Evaluate electrolytes.
The first action the nurse should take when using the nursing process is to assess the client's
electrolytes; therefore, the nurse should evaluate the client's laboratory results, including
sodium, potassium, BUN, Hgb, Hct, and protein, to guide the planning of interventions to
correct the imbalances.
77. A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids.
Which of the following actions should the nurse take?
A. Insert the IV catheter into the back of the client's hand.
B. Massage the area of the venipuncture site vigorously.
C. Insert the IV catheter without using a tourniquet.
D. Apply traction to the skin proximal to the insertion site to stabilize the vein.
Answer: Insert the IV catheter without using a tourniquet.
The nurse should insert the IV catheter using the tourniquet minimally or not at all to avoid
injury of fragile skin or veins.
78. A nurse is caring for a client who has a heart murmur. The nurse is preparing to auscultate
the pulmonary valve. Over which of the following locations should the nurse place the bell of
the stethoscope?
A. Second intercostal space at the left sternal border
B. Fourth intercostal space at the right sternal border
C. Fourth intercostal space at the left sternal border
D. Second intercostal space at the right sternal border
Answer: Second intercostal space at the left sternal border
This is the area over the pulmonary valve. The nurse should listen over this, the apex, and the
other valve areas for rate and rhythm, as well as gallops and murmurs.
79. A nurse is caring for a client who has a terminal illness and is approaching death. The
client's respirations are noisy from secretions in her airway and she is short of breath. Which
of the following actions should the nurse take?
A. Turn the client every 4 hr.
B. Elevate the head of the client's bed.
C. Hold oral care.
D. Increase the room's temperature.
Answer: Elevate the head of the client's bed.
This action promotes postural drainage and also allows maximal chest expansion, which
makes it easier for the client to breathe and decreases noisy respirations.
80. A nurse is caring for a client who has a terminal diagnosis and whose health is declining.
The client requests information about advance directives. Which of the following responses
should the nurse make?
A. "We can talk about advance directives, and I can also give you some brochures about
them."
B. "You should set up a time to talk with your provider about that."
C. "Let's discuss how you are feeling today, and we'll save the planning for when you are
feeling a little better."
D. "Why do you want to discuss this without your partner here to plan this with you?"
Answer: "We can talk about advance directives, and I can also give you some brochures
about them.
" With this statement, the nurse offers to provide the information the client needs in a direct
and simple way.
81. A nurse is assessing a client who reports increased pain following physical therapy.
Which of the following questions should the nurse ask when assessing the quality of the
client's pain?
A. "Is your pain constant or intermittent?"
B. "What would you rate your pain on a scale of 0 to 10?"
C. "Does the pain radiate?"
D. "Is your pain sharp or dull?"
Answer: "Is your pain sharp or dull?"
Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning,
electric- like, or shooting helps determine the quality of the pain.
82. A nurse is giving a change-of-shift report about a client he admitted earlier that day who
has pneumonia. Which of the following pieces of information is the priority for the nurse to
provide?
A. Admitting diagnosis
B. Breath sounds
C. Body temperature
D. Diagnostic test results
Answer: Breath sounds
When using the airway, breathing, circulation approach to client care, the nurse should
determine that the priority information to provide is the current status of the client's breath
sounds.
83. A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of
the following findings should the nurse expect?
A. Albumin level of 3 g/dL
B. HDL level of 90 mg/dL
C. Norton scale score of 18
D. Braden scale score of 20
Answer: Albumin level of 3 g/dL
An albumin level below 3.5 g/dL indicates protein deficiency, placing the client at risk for
pressure ulcer formation and poor wound healing.
84. A nurse is completing an admission assessment of an older adult client. Which of the
following findings should the nurse identify as a potential indication of abuse?
A. Loss of skin turgor on the back of the hands
B. Varicosities on the lower extremities
C. Thick, discoloured nails with ridges
D. Bruises on the arms in various stages of healing
Answer: Bruises on the arms in various stages of healing
Bruises in various stages of healing is an indicator of abuse. Other indicators include burns,
abrasions, fractures, bite marks, dried blood, and pressure ulcers.
85. A nurse is caring for a client who is postoperative and has signs of haemorrhagic shock.
When the nurse notifies the surgeon, he directs her to continue to measure the client's vital
signs every 15 min and call him back in1 hr. From a legal perspective, which of the following
actions should the nurse take next?
A. Document the provider's statement in the medical record.
B. Notify the nursing manager.
C. Consult the facility's risk manager.
D. Complete an incident report.
Answer: Notify the nursing manager.
The greatest risk to the client is not receiving timely intervention for his deterioration in
physiological status; therefore, the next action the nurse should take is to activate the chain
of command to ensure the necessary care is provided to the client.
86. A nurse is caring for a client who is receiving parenteral fluid therapy via a peripheral IV
catheter. After which of the following observations should the nurse remove the IV catheter?
A. Small air bubbles are in the IV tubing.
B. IV flow stops when the client bends her arm.
C. Swelling and coolness are observed at the IV site.
D. Blood is visible in the IV catheter and tubing.
Answer: Swelling and coolness are observed at the IV site.
Swelling and coolness are indications of IV infiltration, which warrant removing the catheter
and restarting the IV infusion with a new catheter at a different site.
87. A client who is non-ambulatory notifies the nurse that his trash can is on fire. After the
nurse confirms the fire, which of the following actions should the nurse take next?
A. Activate the emergency fire alarm.
B. Extinguish the fire.
C. Evacuate the client.
D. Confine the fire.
Answer: Evacuate the client.
According to the RACE mnemonic, the first action in response to a fire is to rescue the clients,
moving them to a safe area.
88. A nurse in a provider's office is obtaining the health and medication history of a client
who has a respiratory infection. The client tells the nurse that she is not aware of any
allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of
the following information should the nurse give the client?
A. "Rashes are very common, especially if you have dry skin. Did it go away on its own?"
B. "Virtually all medications have adverse effects. It sounds like this could have been an
adverse effect of the antibiotic."
C. "It's unlikely that your doctor will prescribe an antibiotic for what seems to be a minor
viral infection, so we shouldn't be concerned about that rash."
D. "We need to document the exact medication you were taking because you might be
allergic to it."
Answer: "We need to document the exact medication you were taking because you might be
allergic to it."
If there is any possibility that a client had an allergic reaction to a medication, itis imperative
that the provider be aware and does not prescribe that same medication again. Subsequent
allergic reactions could be life-threatening.
89. A home health nurse who has attended a training session for the therapeutic use of
aromatherapy with essential oils is planning to use this modality with some of her clients. For
which of the following clients should the nurse consult the provider before using this
complementary therapy?
A. A client who has a history of physical abuse
B. A client who has a permanent pacemaker
C. A client who has ulcerative colitis
D. A client who has asthma
Answer: A client who has asthma
Some essential oils can cause bronchospasm; therefore, the nurse should consult the client's
provider before using this therapy.
90. A nurse on a medical-surgical unit is caring for a client who has a new prescription for
wrist restraints. Which of the following actions should the nurse take?
A. Pad the client's wrist before applying the restraints.
B. Evaluate the client's circulation once per shift after application.
C. Remove the restraints every 4 hr to evaluate the client's status.
D. Secure the restraint ties to the client's bed side rails.
Answer: Pad the client's wrist before applying the restraints.
Restraints without padding can abrade the client's skin.
91. A nurse is caring for a client who is postoperative following knee arthroplasty and
requires the use of a thigh-length sequential compression device. Which of the following
actions should the nurse take?
A. Assist the client into a prone position.
B. Place a sleeve over the top of each leg with the opening at the knee.
C. Make sure two fingers can fit under the sleeves.
D. Set the ankle pressure at 65 mm Hg.
Answer: Make sure two fingers can fit under the sleeves.
Less space than two fingers between the sleeves and the legs can inhibit circulation when the
sleeves inflate.
92. A nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hr.
The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to
the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Answer: 107 mL/hr
The calculation ensures that the total volume of the IV solution is administered evenly over
the prescribed period. By setting the pump to 107 mL/hr, the nurse ensures that 750 mL of
fluid will be delivered over the course of 7 hours, adhering to the prescribed rate of infusion.
93. A nurse is initiating a protective environment for a client who has had an allogeneic stem
cell transplant. Which of the following precautions should the nurse plan for this client?
A. Make sure the client's room has at least 6 air exchanges per hour.
B. Make sure the client wears a mask when outside her room if there is construction in the
area.
C. Place the client in a private room with negative-pressure airflow.
D. Wear an N95 respirator when giving the client direct care.
Answer: Make sure the client wears a mask when outside her room if there is construction in
the area.
An allogeneic stem cell transplant compromises the client's immune system, putting her at
high risk for infection. The client will need protection from breathing in any pathogens in the
environment.
94. A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the
following actions should the nurse take?
A. Administer the medication with the needle at a 45° angle.
B. Administer the medication into the client's nondominant arm.
C. Pull the client's skin laterally or downward prior to administration.
D. Massage the injection site after administration.
Answer: Administer the medication with the needle at a 45° angle.
The nurse should insert the needle for a subcutaneous injection at a 45° to 90°angle.
95. A nurse is caring for a child who has a prescription for a blood transfusion. The parents
have refused the treatment due to religious beliefs. Which of the following actions should the
nurse take?
A. Examine personal values about the issue.
B. Tell the parents that this is a necessary procedure.
C. Inform the parents that the staff does not require their consent.
D. Contact a spiritual support person to explain the importance of the procedure.
Answer: Examine personal values about the issue.
The nurse should examine her own personal values about the issue to help her provide care
that is without bias.
96. A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following
items should the nurse plan to document on the client's intake and output record as 120 mL of
fluid?
A. 2 cups of soup
B. 1 quart of water
C. 8 oz of ice chips
D. 6 oz of tea
Answer: 8 oz of ice chips
The nurse should document half of the volume of ice chips when calculating fluid intake to
account for the air in between the chips. Four oz of liquid water equals120 mL of fluid.
97. A nurse is planning teaching for a group of adolescents who each recently had surgical
placement of an ostomy. Which of the following methods should the nurse use as a
psychomotor approach to learning?
A. Role play
B. Group discussions
C. Question-answer meetings
D. Practice sessions
Answer: Practice sessions
Practice sessions require psychomotor skills when learning.
98. A nurse is teaching a client and his family how to care for the client's tracheostomy at
home. Which of the following instructions should the nurse include in the teaching?
A. Remove the outer cannula cautiously for routine cleaning.
B. Use tracheostomy covers when outdoors.
C. Use sterile technique when performing tracheostomy care at home.
D. Cleanse irritated skin with full-strength hydrogen peroxide.
Answer: Use tracheostomy covers when outdoors.
Tracheostomy covers protect the client's airway from cold air, dust, and other airborne
particles.
99. A nurse is educating a client who has a terminal illness about her request to decline
resuscitation in her living will. The client asks what would happen if she arrived at the
emergency department and had difficulty breathing. Which of the following responses should
the nurse provide?
A. "We will determine who the durable power of attorney for health care form has
designated."
B. "We will apply oxygen through a tube in your nose."
C. "We will ask if you have changed your mind."
D. "We will insert a breathing tube while we evaluate your condition."
Answer: "We will apply oxygen through a tube in your nose."
Oxygen can provide comfort and is not resuscitative when the nurse delivers it via nasal
cannula.
100. A nurse is reviewing evidence-based practice principles about administration of oxygen
therapy with a newly licensed nurse. Which of the following actions should the nurse
include?
A. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter.
B. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min.
C. Make sure the reservoir bag of a partial rebreathing mask remains deflated.
D. Use petroleum jelly to lubricate the client's nares, face, and lips.
Answer: Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min.
Evidence-based practice supports a flow rate of 1 to 6 L/min via nasal cannula.
Rates above 6 L/min force clients to swallow air excessively without increasing their fraction
of inspired oxygen (FiO2).
101. A nurse is planning care for a client who has had a stroke, resulting in aphasia and
dysphagia. Which of the following tasks should the nurse assign to an assistive personnel
(AP)? (Select all that apply.)
A. Assist the client with a partial bed bath.
B. Measure the client's BP after the nurse administers an antihypertensive medication.
C. Test the client's swallowing ability by providing thickened liquids.
D. Use a communication board to ask what the client wants for lunch.
E. Irrigate the client's indwelling urinary catheter.
Answer: Assist the client with a partial bed bath
Assisting a client with a bed bath poses minimal risk to the client and fits within the AP's
range of function. Measure the client's BP after the nurse administers an antihypertensive
medication is correct. Measuring a client's BP poses minimal risk to the client and fits within
the AP's range of function.
