ATI Comprehensive Capstone Exam With Answers-427 Solved Questions

ATI Comprehensive A
1. A client who has a diagnosis of complete placenta previa is admitted to the labor and delivery
suite at 36 weeks gestation with contractions 5 min in frequency and 1 min in duration. Which of
the following actions should the nurse take?
A. Rupture the amniotic sac
B. Medicate the client for pain
C. Prepare the client for a caesarean section
D. Perform a vaginal exam
Answer: C. Prepare the client for a caesarean section
2. A nurse enters a client's room and finds the client lying on the floor in a puddle of water.
Which of the following statements should the nurse document in an incident report?
A. Client fell out of bed because assistive personnel left the rails of the bed down
B. Client's roommate thinks the client is confused and fell when getting out of bed
C. Client appears to have slipped in water but reports no injuries
D. Client found lying on the floor near the bedside table
Answer: D. Client found lying on the floor near the bedside table
3. A charge nurse on a paediatric unit is making assignments for a float nurse from the medical
unit. Which of the following clients is appropriate to assign to the float nurse?
A. A 10-year-old client who has pneumonia and is receiving respiratory treatments
B. A 4-year-old client who has a Wilms tumour and is receiving chemotherapy
C. An 8-month-old client who is scheduled for a surgical repair of a ventricular septal defect
tomorrow
D. A 14-year-old client who is scheduled for discharge today following placement of a
Herrington rod
Answer: A. A 10-year-old client who has pneumonia and is receiving respiratory treatments
4. A nurse is preparing to administer vancomycin to a client who has an infected wound. The
nurse should plan to monitor for which of the following adverse reactions?

A. Hepatotoxicity
B. Ototoxicity
C. Hypercalcemia
D. Hypertension
Answer: B. Ototoxicity
5. A nurse is assessing an infant who has water intoxication. Which of the following findings
should the nurse expect?
A. Generalized edema
B. Elevated urine specific gravity
C. Thready pulse
D. Increased hematocrit
Answer: C. Thready pulse
6. A home health nurse is conducting an initial home visit for a client who has terminal breast
cancer. The client has two school-age children and a limited support system. Which of the
following is the priority nursing action?
A. Inform the client of available community resources
B. Assist the client in finding child care options
C. Agree upon short-term goals for the client
D. Ask the client about their understanding of the diagnosis
Answer: A. Inform the client of available community resources
7. A nurse in an emergency department is assessing a client who has a nasal fracture. Which of
the following findings should cause the nurse to suspect a skull fracture?
A. Clear fluid drainage from the nares
B. Report of pain around the eyes
C. Dried blood in the mouth
D. Mandibular asymmetry
Answer: A. Clear fluid drainage from the nares

8. A nurse in an urgent care clinic is collecting admission history from a client who is at 16
weeks of gestation and has bacterial vaginosis. The nurse should recognize that which of the
following clinical findings are associated with this infection?
A. Profuse milky white discharge
B. Frequency and dysuria
C. Low-grade fever
D. Hematuria
Answer: A. Profuse milky white discharge
9. A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse.
Which of the following statements indicates the newly licensed nurse understands the purpose of
the technique?
A. This technique prevents injury to the sciatic nerve
B. This technique decreases the risk of subcutaneous infiltration
C. This technique allows a larger amount of medication to be injected
D. This technique increases the absorption rate of the drug
Answer: B. This technique decreases the risk of subcutaneous infiltration
10. A nurse is caring for a full-term newborn immediately following birth. Which of the
following actions should the nurse take first?
A. Instill erythromycin ophthalmic ointment in the newborn's eyes
B. Weigh the newborn
C. Place identification bracelets on the newborn
D. Dry the newborn
Answer: D. Dry the newborn
11. A nurse is planning to provide community education about viral hepatitis. Which of the
following should the nurse plan to include in the teaching?
A. A series of four hepatitis vaccines is recommended to prevent viral hepatitis
B. Hepatitis B is transmitted by contaminated food
C. Chronic hepatitis can lead to renal cell cancer

D. Clients who have a history of viral hepatitis are unable to donate blood
Answer: D. Clients who have a history of viral hepatitis are unable to donate blood
12. A nurse in a residential mental health facility is planning care for a new client who has
obsessive compulsive disorder. Which of the following is appropriate for the nurse to include in
the plan of care?
A. Work with the client to create a flexible daily schedule
B. Gradually decrease the time allowed for ritualistic behavior
C. Offer solutions to assist in problem solving
D. Teach the client to meditate about obsessive thoughts
Answer: A. Work with the client to create a flexible daily schedule
13. A nurse is assessing an adult male who has a BMI of 20. The nurse should identify that the
client's BMI falls within which of the following categories?
A. Healthy weight
B. Malnutrition
C. Overweight
D. Obesity
Answer: B. Malnutrition
14. A nurse is caring for a client who is nulliparous and in the first stage of labor. The last
internal assessment revealed 100% cervical effacement with 5 cm of dilation. At the end of the
last contraction, the nurse observes a large gush of fluid coming out of the client's perineal area.
Which of the following is a priority action by the nurse?
A. Perform another internal exam
B. Notify the client's provider
C. Check the FHR
D. Obtain a pH test of the fluid
Answer: C. Check the FHR

15. A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the
following interventions should the nurse include in the plan?
A. Encourage the client to gain 2.3 kg per week
B. Weigh the client once per week throughout hospitalization
C. Monitor the client for 1 hr after meals
D. Allow the client to choose meal times
Answer: C. Monitor the client for 1 hr after meals
16. A nurse is performing a skin assessment on a client who has risk factors for development of
skin cancer. The nurse should understand that a suspicious lesion is
A. Asymmetric, with variegated coloring
B. Scaly and red
C. Brown, with a wart-like texture
D. Firm and rubbery
Answer: A. Asymmetric, with variegated coloring
17. A nurse is assessing a client's internal eye structures with an ophthalmoscope. Which of the
following actions should the nurse take?
A. Position the examination light toward the client's face
B. Stand on the right side of the client when examining the left eye
C. Dim the lights in the room prior to the examination
D. Place the ophthalmoscope directly against the client's forehead
Answer: C. Dim the lights in the room prior to the examination
18. A nurse is observing a newly licensed nurse irrigate a client's wound. Which of the following
actions should the nurse identify as an indication that the newly licensed nurse understands
wound irrigation?
A. Cleanses the wound with povidone-iodine with cotton balls
B. Administers PO analgesia 20 min prior to irrigation
C. Warms the irrigation solution in the microwave oven prior to application
D. Irrigates the wound from the top to the bottom

Answer: B. Administers PO analgesia 20 min prior to irrigation
19. A nurse is planning care for a child who has increased intracranial pressure with a decrease in
level of consciousness. Which of the following interventions should the nurse include in the plan
of care?
A. Perform active range-of-motion exercises
B. Maintain the head at a midline position
C. Suction the airway frequently
D. Perform neurological checks every 4 hrs
Answer: B. Maintain the head at a midline position
20. A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket.
After moving the client to safety, which of the followings is the priority action?
A. Notify the facility operator
B. Close the fire doors on the unit
C. Turn off oxygen sources
D. Put out the fire with the appropriate extinguisher
Answer: B. Close the fire doors on the unit
21. A nurse is talking with an adult child of a client who was involuntarily admitted to an
inpatient mental health facility. Which of the following statements should the nurse make?
A. The provider will notify your patient's employer about admission to the facility
B. Your parent will have to take the medication that the doctor prescribes
C. Your parent might have electroconvulsive therapy without providing consent
D. The provider can prescribe restraints if your parent tries to harm others
Answer: D. The provider can prescribe restraints if your parent tries to harm others
22. A nurse is assessing a client who has delirium due to a febrile illness. Which of the following
findings should the nurse expect?
A. Hallucinations
B. Agnosia

C. Bradycardia
D. Aphasia
Answer: A. Hallucinations
23. A nurse is assessing a client who is receiving enteral feedings via a gastrostomy tube. The
nurse should identify that which of the following findings indicates fluid overload?
A. Diminished bowel sounds
B. Bradycardia
C. Hypotension
D. Bounding pulses
Answer: D. Bounding pulses
24. A nurse is caring for a client following an open colectomy. Which of the following findings
places the client at risk for delayed wound healing?
A. INR 1.1
B. Hyperemesis
C. HbA1c 5.6%
D. Uncontrolled pain
Answer: B. Hyperemesis
25. A nurse is assessing a client who has a complete heart block and is receiving transcutaneous
pacing. Which of the following findings indicates to the nurse that the treatment is effective?
A. Heart rate greater than 60/min
B. Pedal pulses 2+
C. Pacer spikes after the QRS complex
D. Distended jugular veins
Answer: A. Heart rate greater than 60/min
26. A nurse is caring for a client who is taking levothyroxine. Which of the following findings
should indicate to the nurse that the medication is effective?
A. Decreased blood pressure

B. Weight loss
C. Decreased inflammation
D. Absence of seizures
Answer: B. Weight loss
27. A nurse at the family planning clinic triages several client over the phone. Which of the
following clients should the nurse instruct to come to the clinic?
A. A client who uses a diaphragm for contraception and has lost 30 lb in the past 6 months
dieting
B. A client who had an intrauterine device inserted yesterday and has cramping and bleeding
C. A client who has started taking oral contraceptives and is experiencing bright red vaginal
breakthrough bleeding
D. A client who has sharp pain in her shoulder following a laparoscopic tubal ligation yesterday
Answer: D. A client who has sharp pain in her shoulder following a laparoscopic tubal ligation
yesterday
28. A home health nurse is reviewing treatment goals with a client who has diabetes mellitus.
The nurse should evaluate which of the following laboratory tests to determine effective longterm management of blood glucose levels?
A. 3-hr oral glucose tolerance test
B. HbA1c
C. Fasting blood glucose test
D. Urinalysis for ketones
Answer: B. HbA1c
29. A nurse is caring for a client who has neutropenia due to HIV. Which of the following
precautions should the nurse take while caring for this client?
A. Wear an N95 respirator
B. Insert an indwelling urinary catheter to monitor urinary output
C. Monitor the client's vital signs every 8 hr
D. Use a dedicated stethoscope

Answer: D. Use a dedicated stethoscope
30. A nurse is planning care for a client who has a gambling disorder. Which of the following
instructions should the nurse provide to the client?
A. Participate in a 12-step program
B. Plan to take clozapine for the next 6 months
C. Use systematic desensitization to decrease gambling behaviours
D. Learn to use projection to adapt to stressful experiences
Answer: A. Participate in a 12-step program
31. A nurse is caring for a client who reports difficulty falling asleep at night. Which of the
following actions should the nurse take?
A. Encourage the client to ambulate in the hallway 1 hr before bedtime
B. Tell the client to avoid drinking fluids 1 hr before bedtime
C. Schedule routine care tasks during hours when the client is awake
D. Advise the client to leave the television in the room on when trying to fall asleep
Answer: B. Tell the client to avoid drinking fluids 1 hr before bedtime
32. A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive
phototherapy. Which of the following interventions should the nurse include?
A. Clothe the newborn in light cotton
B. Check the newborn's temperature every 8 hrs.
C. Administer 120 mL of water between feedings
D. Place the newborn 45 cm from the light source
Answer: D. Place the newborn 45 cm from the light source
33. A nurse is providing teaching to a client who is at 8 week gestation and experiencing
episodes of nausea and vomiting. Which of the following instructions should the nurse include?
A. Brush teeth immediately after eating
B. Lay down for 30 min after meals
C. Drink 12 oz of water with each meal

D. Eat a dry carbohydrate before getting out of bed
Answer: D. Eat a dry carbohydrate before getting out of bed
34. A nurse is teaching a client who is scheduled for placement of a peripherally inserted central
catheter line. Which of the following information should the nurse include in the teaching?
A. Your PICC line will allow long-term access for antibody therapy
B. You should use a 5-milliliter barrel syringe to flush your PICC line at home
C. Your PICC line must be placed in your nondominant arm
D. You should immobilize the arm with the PICC line using a sling
Answer: A. Your PICC line will allow long-term access for antibody therapy
35. A nurse is planning care for a client who has schizophrenia and is having difficulty
expressing their feelings. Which of the following referrals should the nurse make?
A. Art therapist
B. Speech-language pathologist
C. Social worker
D. Recreational therapist
Answer: C. Social worker
36. A nurse in a mental health clinic is observing clients in the day room. The nurse sits down to
talk with an adolescent client who was admitted with clinical depression. After a few minutes of
conversation, the adolescent asks the nurse, "Why did you choose to talk to me out of this room
full of kids?" Which of the following responses by the nurse is therapeutic?
A. You looked like you would be the most likely to talk back with me
B. Let's go see what activities are going on outside
C. Why shouldn't I talk to you? You looked lonely
D. You're curious why I am interested in you and not the others?
Answer: D. You're curious why I am interested in you and not the others?

37. An occupational health nurse at a group of health care clinics is planning activities to prevent
and control the spread of communicable disease. The nurse should identify that which of the
following activities is a secondary level of prevention?
A. Influenze immunizations
B. Tuberculosis screenings
C. Presentations about safer sex practices
D. Evaluations of bloodborne pathogen policies
Answer: B. Tuberculosis screenings
38. A nurse is caring for a client who has heart failure and has started taking a loop diuretic.
Which of the following findings indicates the client is experiencing an adverse effect of the
medication
A. Decreased reflexes
B. Weight gain of 1.4 kg
C. Increased urinary output
D. Jugular vein distention
Answer: A. Decreased reflexes
39. A nurse is caring for a client who is postoperative following a bowel surgery and has an NG
tube connected to low intermittent suction. Which of the following assessment findings should
indicate to the nurse that the NG tube might not be functioning properly?
A. Wall suction set to 60 mmHg
B. Drainage fluid is greenish-yellow
C. Aspirate pH of 3
D. Abdominal rigidity
Answer: D. Abdominal rigidity
40. A nurse is caring for a 7-year-old child who has severe dehydration. Which of the following
findings should the nurse expect?
A. Blood pressure 94/68 mmHg
B. Urinary output 30 mL/hr

C. Respiratory rate 24/min
D. Heart rate 152/min
Answer: D. Heart rate 152/min
41. A client who is having suicidal thoughts tells the nurse, "It just does not seem worth it. Why
not end my misery?" Which of the following responses by the nurse is appropriate?
A. Why do you think your like is not worth it anymore?
B. You can trust me and tell me what you are thinking?
C. I need to know what you mean by misery?
D. Do you have to plan to end your life?
Answer: D. Do you have to plan to end your life?
42. A nurse is caring for a client who has schizophrenia. Which of the following findings is the
nurse's priority?
A. The client asks other clients on the unit for help with bathing and getting dressed
B. The client refuses to take prescribed oral risperidone
C. The client reports hearing voices
D. The client's thoughts jump rapidly from one idea to the next when speaking
Answer: C. The client reports hearing voices
43. At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a
list of client reports. Which of the following client reports should the nurse assess first?
A. Constipation
B. Indigestion
C. Swollen ankles
D. Urinary frequency
Answer: B. Indigestion
44. A nurse is caring for a client who has just returned to the unit following a bronchoscopy.
Which of the following actions by the assistive personnel requires the nurse to intervene?
A. Encourages the client to use the incentive spirometer

B. Elevates the head of the client's bed
C. Offers oral fluids to the client
D. Checks the client's pulse oximetry
Answer: C. Offers oral fluids to the client
45. A nurse is reviewing the medical history of a client who is taking a garlic supplement. The
nurse should identify that which of the following findings is a contraindication for taking this
supplement?
A. The client is taking an antidepressant
B. The client has a history of a seizure disorder
C. The client takes aspirin daily
D. The client has a history of rheumatoid arthritis
Answer: C. The client takes aspirin daily
46. A nurse in a mental health facility is interviewing a newly admitted client. Which of the
following actions should the nurse take when conducting the interview?
A. Insist the client use direct eye contact during the interview
B. Seat the client at least 3.7m from the nurse
C. Position the client's chair between the nurse's chair and the door
D. Lean in slightly when speaking to the client
Answer: B. Seat the client at least 3.7m from the nurse
47. A nurse on a medical unit has just received change-of-shift report. Which of the following
clients should the nurse assess first?
A. A 68 year old client who had a myocardial infarction 2 days ago and reports chest pain on a
scale of 0 to 10
B. A 48 year old client who has AIDS, pneumocystis pneumonia, and a temperature of 38.3 C
(101F)
C. A 60 year old client who has COPD, is receiving 2 L/min O2 via a nasal cannula, and has an
oxygen saturation of 89%
D. A 26 year old female client who has pelvic inflammatory disease and is unable to void

Answer: A. A 68 year old client who had a myocardial infarction 2 days ago and reports chest
pain on a scale of 0 to 10
48. A nurse is assessing a client prior to performing a blood draw. The nurse should identify that
an allergy to which of the following food can indicate that the client has an allergy to latex?
A. Peanuts
B. Shellfish
C. Avocados
D. Eggs
Answer: C. Avocados
49. A nurse is planning discharge teaching for a client who is scheduled to receive intravenous
infusions at home. Which of the following instructions should the nurse plan to include?
A. Plug the infusion pump in an outlet next to the bathroom
B. Pull the cord when unplugging the infusion pump
C. Clean the infusion pump when it is turned on
D. Place the infusion pump cord against the baseboards
Answer: D. Place the infusion pump cord against the baseboards
50. A nurse is preparing to witness a client's signature on an informed consent for a total knee
arthroplasty. Which of the following client statements indicates the nurse should contact the
surgeon?
A. I wonder if the metal in my knee will show up in airport screenings
B. The physical therapy has not been working, so I will need to have the surgery
C. I look forward to being able to bend my knee again when I sit in a chair
D. I am thankful there are no serious complications from this type of surgery
Answer: D. I am thankful there are no serious complications from this type of surgery
51. A nurse plans to ambulate a client on the third day after cardiac surgery. Which of the
following interventions should the nurse take so that the client will best tolerate ambulation?
A. Provide the client with a water

B. Premedicate the client with the prescribed analgesic
C. Obtain the client's vital signs and oximetry prior to ambulation
D. Reinforce the client's surgical dressing
Answer: B. Premedicate the client with the prescribed analgesic
52. A nurse is planning the discharge of an infant who has tetralogy of Fallot. The nurse
anticipates the need for which of the following equipment?
A. Portable suction
B. Cervical collar
C. Hemodialyzer
D. Pulse oximeter
Answer: D. Pulse oximeter
53. A nurse is admitting a client who has antisocial personality disorder. Which of the following
client behaviours should the nurse identify as consistent with this disorder?
A. Compulsive attention to details
B. Avoids interacting with others
C. Uses others for personal gain
D. Socially awkward in group situations
Answer: C. Uses others for personal gain
54. A nurse is teaching the parent of a school-age child who has scabies about the application of
permethrin 5% cream. The nurse should include which of the following as a potential adverse
effect of the medication?
A. Burning
B. Discoloration
C. Photosensitivity
D. Alopecia
Answer: A. Burning

55. A nurse is teaching a client who has a new prescription for digoxin. Which of the following
statements should the nurse include in the teaching?
A. "Notify your provider if you experience muscle weakness."
B. "Reports a weight gain of one-half pound per day."
C. "Expect this medication to increase your blood pressure."
D. "You will need to take a diuretic while taking this medication."
Answer: B. "Reports a weight gain of one-half pound per day."
56. A nurse is planning teaching for a client who is at 10 weeks of gestation and has a history of
urinary tract infections. Which of the following information should the nurse plan to include in
the teaching about UTI prevention?
A. Decrease intake of citrus foods and beverages
B. Wear nylon underwear
C. Empty the bladder before and after intercourse
D. Increase the time between voiding
Answer: C. Empty the bladder before and after intercourse
57. A nurse is providing discharge teaching to a client who is postpartum and plans to breastfeed.
Which of the following should the nurse recommend the client increase in their diet during
lactation?
A. Vitamin D
B. Iron
C. Vitamin A
D. Calcium
Answer: D. Calcium
58. A nurse is caring for a client who has been taking propranolol. Which of the following
findings indicates a need to withhold the medication?
A. Blood pressure 156/90 mm Hg
B. Pulse 54/min
C. Potassium 5.2 mEq/L

D. Sodium 130 mEq/L
Answer: B. Pulse 54/min
59. A nurse is providing teaching about preventing mastitis to a client who is postpartum and
breastfeeding her newborn. Which of the following instructions should the nurse include?
A. "Wear an underwire bra between feedings."
B. "Cover your breasts immediately after feedings."
C. "Apply cold compresses to your breasts before feedings."
D. "Try to have your baby empty your breasts with each feeding."
Answer: D. "Try to have your baby empty your breasts with each feeding."
60. A nurse is caring for a client who is receiving total parenteral nutrition. Which of the
following findings requires immediate intervention by the nurse?
A. Blood glucose level of 120 mg/dL
B. Serum sodium 138 mEq/L
C. Oral temperature of 37.6C
D. Weight increase of 2 kg in the past 24 hours
Answer: D. Weight increase of 2 kg in the past 24 hours
61. A nurse is caring for a client who reports chest pain. Which of the following findings
indicates myocardial damage?
A. aPTT 80 seconds
B. Troponin I 1.8 ng/mL
C. Erythrocyte sedimentation rate 17 mm/hr
D. Human B-type natriuretic peptide 88 pg/mL
Answer: B. Troponin I 1.8 ng/mL
62. A nurse is assessing a client who has a fentanyl patch in place for chronic pain. Which of the
following findings should the nurse report to the provider?
A. No bowel movement for 3 days
B. Report of dry mouth

C. Respiratory rate 14/min
D. Potassium level 4.8 mEq/L
Answer: A. No bowel movement for 3 days
63. A nurse is providing teaching to a client who has osteoporosis and a new prescription for
alendronate. Which of the following statements by the client indicates an understanding of the
teaching?
A. "I will take this medication within 15 minutes of eating."
B. "I will take this medication at bedtime."
C. "I will take this medication with 8 ounces of water."
D. "I will increase my caffeine intake while taking this medication."
Answer: C. "I will take this medication with 8 ounces of water."
64. A nurse is caring for a client who experienced a stroke and has dysphagia. Which of the
following findings should indicate to the nurse the client is at risk for aspiration?
A. The client tucks his chin while swallowing food
B. The client sits upright in bed during meals
C. The client pockets food on one side of his mouth
D. The client has a cough reflex
Answer: C. The client pockets food on one side of his mouth
65. A nurse is caring for a group of clients. Which of the following clients should the nurse
assign to an assistive personnel?
A. A client who has chronic obstructive pulmonary disease and needs guidance on incentive
spirometry
B. A client who had a myocardial infarction 3 days ago and reports chest pain
C. A client who had a stroke 2 days ago and needs help toileting
D. A client who has awoken following a bronchoscopy and requests a drink
Answer: C. A client who had a stroke 2 days ago and needs help toileting

66. A nurse is caring for a client who is receiving continuous enteral feedings and reports
diarrhea. Which of the following actions should the nurse take?
A. Discard opened cans of formula after 24 hrs
B. Replace the extension tubing every 48 hrs
C. Irrigate the tubing every 12 hr with 50 mL of warm water
D. Increase the infusion rate
Answer: A. Discard opened cans of formula after 24 hrs
67. A nurse is caring for an adolescent who is receiving treatment for heart failure. Based on the
client's chart findings, which of the following actions should the nurse plan to take?
A. Administer furosemide
B. Withhold digoxin
C. Withhold spironolactone
D. Administer ferrous sulphate
Answer: B. Withhold digoxin
68. A nurse is reviewing the employee health program for new employees. Which of the
following diagnostic assessments should the nurse recommend for all new employees to screen
for the presence of tuberculosis?
A. Sputum culture
B. Chest x-ray
C. QuantiFERON-TB Gold blood analysis
D. Mantoux test
Answer: D. Mantoux test
69. A nurse is providing teaching about car seat safety to the parent of a term newborn. Which of
the following statements by the parent indicates an understanding of the teaching?
A. "I should place a rolled blanket along each side of my baby's head in the car seat."
B. "I should place my baby's car seat rear-facing until 6 months of age."
C. "I should put the car seat retainer clip at the level of my baby's belly button."
D. "I should position my baby's car seat at a 90-degree angle in the car."

Answer: B. "I should place my baby's car seat rear-facing until 6 months of age."
70. A nurse in the labor and delivery unit is reviewing medications for a group of clients. Which
of the following medications places the fetus at risk for teratogenic effects?
A. Levothyroxine for hypothyroidism
B. Phenytoin for seizure disorder
C. Magnesium oxide for constipation
D. Ferrous sulfate for chronic anaemia
Answer: B. Phenytoin for seizure disorder
71. An emergency department nurse triages a group of school children injured in a school bus
crash. Which of the following children should the nurse have the provider evaluate first?
A. A child who has a forehead wound that is bleeding copiously
B. A child who has a compound fracture of the femur and is crying in pain
C. A child who reports diplopia and nausea and was unconscious at the scene but is now awake
D. A child who has several missing permanent teeth and a swollen, ecchymotic upper lip
Answer: A. A child who has a forehead wound that is bleeding copiously
72. A nurse is caring for a client who is receiving total parental nutrition. For which of the
following findings should the nurse monitor as a potential complication of TPN?
A. Constipation
B. Respiratory depression
C. Hypotension
D. Electrolyte imbalance
Answer: D. Electrolyte imbalance
73. A nurse is analysing the laboratory data on a client who has dehydration. Which finding
should the nurse anticipate in a client who has fluid volume deficit?
A. Decreased serum osmolarity
B. Decreased haematocrit
C. Elevated blood urea nitrogen

D. Lower urine specific gravity
Answer: C. Elevated blood urea nitrogen
74. A nurse is performing high-frequency chest compressions using a mechanical chest
compression device for a child who has cystic fibrosis. Which of the following findings indicates
the treatment has been effective?
A. The child develops a dry, hacking cough
B. The child has increased nasal secretions
C. The child has increased sputum production
D. The child develops diminished breath sounds
Answer: C. The child has increased sputum production
75. A nurse in an inpatient mental health facility is caring for a client who has major depressive
disorder and refuses to take her medication. Which of the following actions should the nurse take
first?
A. Explain to the client the consequences of refusal
B. Identify the reason for the client's refusal
C. Document the client's refusal in the medical record
D. Inform the provider of the client's refusal
Answer: B. Identify the reason for the client's refusal
76. A nurse is providing discharge teaching about disease prevention to a client who has active
tuberculosis. Which of the following should the nurse include?
A. Educating the client how to cover nose and mouth with tissues when coughing
B. Recommending the client may return to work after two negative sputum cultures
C. Instructing the client that he is no longer contagious after 1 week of medication therapy
D. Teaching the client's family to wear protective masks while with the client
Answer: A. Educating the client how to cover nose and mouth with tissues when coughing
77. A nurse is caring for a client following a possible exposure to anthrax. Which of the
following actions should the nurse take?

A. Administer an antitoxin
B. Quarantine the client
C. Monitor the client for a productive cough
D. Begin prophylactic treatment with ciprofloxacin
Answer: A. Administer an antitoxin
78. A nurse is caring for a client who has a newly implanted sealed internal radiation device to
treat cervical cancer. Which of the following is an appropriate action for the nurse to take?
A. Prohibit visitors for the first 24 hrs
B. Keep a 3 foot distance from the radiation implant
C. Maintain the client on bed rest for 72 hr
D. Require the client wear a dosimeter badge
Answer: B. Keep a 3 foot distance from the radiation implant
79. A nurse is admitting a client to the medical-surgical unit. Which of the following actions
should the nurse take first?
A. Place the client's valuables in the facility's safe
B. Observe the client's level of mobility
C. Administer prescribed medications
D. Electronically enter the prescriptions from the provider
Answer: B. Observe the client's level of mobility
80. A nurse is assessing a client in the PACU. Which of the following findings indicates
decreased cardiac output?
A. Oliguria
B. Constricted pupils
C. Shivering
D. Bradypnea
Answer: A. Oliguria

81. A nurse in a newborn nursery is performing assessments on four neonates that are all less
than 24 hr old. The nurse should plan to notify the provider of which of the following findings?
A. Head circumference 1 cm greater than chest
B. Positive Babinski reflex on bilateral feet
C. Passage of meconium stool
D. Pinna below the outer canthus of the eye
Answer: D. Pinna below the outer canthus of the eye
82. A nurse is providing teaching to the guardian of a school-age child who has a new
prescription for ferrous sulphate capsules PO. Which of the following instructions should the
nurse include in the teaching?
A. Add the contents of the capsules to food
B. Dissolve the capsules in a glass of chocolate milk
C. Administer the medication with a glass of orange juice
D. Administer the medication at bedtime
Answer: C. Administer the medication with a glass of orange juice
83. A nurse at a public health clinic is caring for a group of clients. Which of the following
should the nurse identify as a reportable diagnosis to the CDC?
A. Herpes simplex virus (HSV) type 1
B. Hepatitis A
C. Human papillomavirus (HPV)
D. Pediculosis capitis
Answer: B. Hepatitis A
84. A nurse is giving change of shift report about a client who is 36 hr postoperative to another
nurse. Which of the following should the nurse include?
A. Daily bath given at 1000
B. Vomited a large amount of emesis immediately after surgery
C. Flushed IV with 0.9% sodium chloride
D. Pain relieved by position change

Answer: D. Pain relieved by position change
85. A charge nurse is evaluating the time management skills of a newly licensed nurse. Which of
the following actions should the charge nurse identify as an effective time management skill?
A. Delegates creation of a client's teaching plan to a licensed practical nurse
B. Completes activities for one client before moving to the next client
C. Focuses on activities rather than objectives
D. Skips break times to catch up on charting
Answer: B. Completes activities for one client before moving to the next client
86. A nurse is caring for a client who has a prescription for atorvastatin. Which of the following
client conditions is a contraindication to this medication?
A. Hepatitis C
B. Crohn's disease
C. Peptic ulcer disease
D. Bronchitis
Answer: A. Hepatitis C
87. A nurse delegates tasks to a licensed practical nurse and an assistive personnel. When
admitting a client who is experiencing acute liver failure and who has ascites and an NG tube,
which of the following tasks is most appropriate for the nurse to delegate to the LPN?
A. Insert an indwelling catheter if the client has not voided in 3 hr
B. Obtain the abdominal girth now and every 4 hr
C. Assess and document the level of consciousness every hour
D. Measure the amount of gastric drainage every 2 hr
Answer: A. Insert an indwelling catheter if the client has not voided in 3 hr
88. A nurse is assessing a client who has a long arm cast. For which of the following findings
should the nurse monitor when assessing for acute compartment syndrome
A. Edema
B. Shortness of breath

C. Petechiae
D. Change in mental status
Answer: A. Edema
89. A nurse is caring for a client who has opioid use disorder and is experiencing withdrawal.
Which of the following findings should the nurse expect?
A. Hyperreflexia
B. Meiosis
C. Euphoria
D. Hypothermia
Answer: A. Hyperreflexia
90. A nurse is caring for a client who is at high risk for developing diabetes insipidus following a
severe head injury. Which assessment finding indicates to the nurse that the client is developing
DI?
A. Urine specific gravity of 1.028
B. Urine output of 250 mL/hr
C. Serum sodium of 155 mEq/L
D. Blood glucose of 198 mg/dL
Answer: C. Serum sodium of 155 mEq/L
91. A nurse is planning to perform wound irrigation for a client who has an open secondary
wound. When creating a sterile field, which of the following actions should the nurse take?
A. Set up the sterile field 7.6 cm below waist level
B. Hold the bottle of sterile solution with the palm over the label while pouring
C. Place the sterile items within 1 cm of the edge of the sterile border
D. Place the lid of a bottle of sterile solution within the sterile field
Answer: B. Hold the bottle of sterile solution with the palm over the label while pouring

92. A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The
nurse is reviewing the monitor tracing and notes early decelerations. Which of the following
should the nurse expect?
A. Head compression
B. Fetal hypoxia
C. Abruptio placentae
D. Post maturity
Answer: A. Head compression
93. A nurse is caring for a client who is requesting treatment for a gambling disorder. Which of
the following medications should the nurse expect the provider to prescribe?
A. Varenicline
B. Disulfiram
C. Sertraline
D. Clonidine
Answer: B. Disulfiram
94. A charge nurse overhears two assistive personnel in the unit lobby discussing the HIV status
of a client. Which of the following response is the priority for the nurse to make?
A. Do you understand HIPAA regulations?
B. This discussion is only appropriate in a private area
C. Please stop this discussion
D. Did you know you can be liable if you breach confidentiality?
Answer: C. Please stop this discussion
95. A nurse is planning care for a client who is prescribed a cane for ambulation. Which of the
following actions should the nurse include in the plan of care?
A. Remind the client to place the cane on the unaffected side
B. Adjust the length of the cane to equal the distance from the client's iliac crest to the floor
C. Remove the rubber tip from the cane to enhance ambulation
D. Place the cane safely in the closet during naps and at bedtime

Answer: A. Remind the client to place the cane on the unaffected side
96. A nurse is planning care for a client who has a sealed radiation implant and is to remain in the
hospital for 1 week. Which of the following should the nurse include in the plan of care?
A. Limit each of the client's visitors to 1 hr per day
B. Remove dirty linens from the room after double bagging
C. Wear a dosimeter film badge while in the client's room
D. Ensure family members remain at least 1 m from the client
Answer: C. Wear a dosimeter film badge while in the client's room
97. A nurse is assessing a client who was brought to the emergency department by his adult
child. The client has visible contusions on all four extremities. Which of the following actions
should the nurse take?
A. Report the incident to Adult Protective Services
B. Interview the client with his adult child present
C. Tell the client he must answer every assessment question
D. Advise the client to consult a social worker
Answer: A. Report the incident to Adult Protective Services
98. A home health nurse is assessing a client who reports a headache and appears confused and
drowsy. The client has a kerosene space heater in use. Which of the following actions should the
nurse take first?
A. Take the client outdoors
B. Wrap blankets around the client
C. Loosen the client's clothing
D. Open the client's windows
Answer: A. Take the client outdoors
99. A nurse is caring for a client who reports the use of chondroitin and glucosamine. The health
benefit of this supplement combination is to do which of the following?
A. Treat mild to moderate depression

B. Enhance the immune system
C. Prevent and treat prostate enlargement
D. Improve joint functioning
Answer: D. Improve joint functioning
100. A nurse is assessing a client who is postoperative following abdominal surgery. The client
states, "I feel like my incision ripped open." The nurse notes dehiscence of the incision. Which of
the following actions should the nurse take?
A. Extend the client's legs above heart level
B. Place the client in a low-Fowler's position
C. Instruct the client to perform the Valsalva maneuver
D. Apply a dry gauze dressing to the incision
Answer: A. Extend the client's legs above heart level
101. A nurse is caring for a client who has a hearing impairment. When speaking to the client, the
nurse should incorporate which of the following communication methods?
A. Speak directly into one of the client's ears
B. Rephrase sentences the client does not understand
C. Drop voice volume at the end of sentences
D. Exaggerate lip movements
Answer: B. Rephrase sentences the client does not understand
102. During the immediate postoperative period following thoracic surgery, a nurse medicates a
client for pain on a schedule. The rationale for this nursing action is which of the following?
A. Suppresses the cough reflex
B. Decreases the level of anxiety
C. Reduces the respiratory rate
D. Facilitates deep breathing
Answer: D. Facilitates deep breathing

103. A nurse is providing teaching to the parent of a 6 month old infant who is teething and
having difficulty sleeping. Which of the following instructions should the nurse include?
A. Rub your child's gums with an aspirin tablet before bedtime
B. Place an amber teething necklace on your child before bedtime
C. Administer acetaminophen drops to your child before bedtime
D. Apply a teething product containing benzocaine to your child's gums before bedtime
Answer: C. Administer acetaminophen drops to your child before bedtime
104. A nurse is providing dietary teaching to a client who has an increased cholesterol level.
Which of the following foods should the nurse recommend?
A. Beef liver
B. Egg whites
C. Steamed claims
D. Broiled lobster
Answer: B. Egg whites
105. A nurse is following protocol for preventing puncture injuries. Which of the following
actions should the nurse take?
A. Detach the needle from the syringe before discarding it
B. Place broken glass in a wastebasket
C. Recap the needle after administering an injectable medication
D. Place lancets in a puncture-proof container
Answer: D. Place lancets in a puncture-proof container
106. A home health nurse is teaching a guardian about administering tube feedings to their 3
month old infant. Which of the following information should the nurse include in the teaching?
A. Allow the infant to suck on a pacifier during feedings
B. Place enough formula for 12 hr in the feeding container
C. Change the tube feeding setup every 36 hr
D. Flush the tube with 30 mL of water between feedings
Answer: A. Allow the infant to suck on a pacifier during feedings

107. A nurse in the recovery room is assessing a client who has a new chest tube. The nurse finds
that the water seal is no longer tidaling. The nurse should identify the finding as resulting from
which of the following?
A. An air leak noted at the insertion site
B. The tubing may be kinked
C. Water needs to be added to the suction-control chamber
D. The suction is set too low
Answer: B. The tubing may be kinked
108. A nurse is assessing a client who has pericarditis. Which of the following findings is the
priority?
A. Dependent edema
B. Pericardial friction rub
C. Paradoxical pulse
D. Substernal chest pain
Answer: C. Paradoxical pulse
109. A nurse is assessing a client 1 week after a successful bone marrow transplant. The client
reports peeling of skin on her hands and feet. The nurse should recognize this desquamation as
an indication of which of the following complications?
A. Failure to engraft
B. Veno-occlusive disease
C. Graft-versus-host disease
D. Pancytopenia
Answer: C. Graft-versus-host disease
110. A client has just returned to the nursing unit following cardiac catheterization. In the
immediate post procedure period, which of the following is the priority nursing action?
A. Monitoring the insertion site for infection
B. Checking for orthostatic hypotension

C. Forcing fluids
D. Immobilizing the affect extremity
Answer: D. Immobilizing the affect extremity
111. A nurse is providing dietary teaching for a client who has a history of nephrolithiasis. Which
of the following is appropriate to include in the teaching?
A. Restrict dietary calcium intake
B. Limit fluid intake to 40 oz/day
C. Decrease complex carbohydrates in the diet
D. Avoid foods that have high levels of oxalates
Answer: A. Restrict dietary calcium intake
112. A charge nurse is creating assignments for the next shift for several nurses and one of the
nurses is pregnant. Which of the following clients should the charge nurse assign to a nurse who
is not pregnant?
A. A 60 year old client who is recovering from shingles
B. A 20 year old client who is HIV positive
C. A 40 year old client who is suspected of having tuberculosis
D. An 80 year old client who has alcoholic pancreatitis and is being treated for impetigo
Answer: A. A 60 year old client who is recovering from shingles
113. A nurse is teaching a newly licensed nurse about informed consent. Which of the following
statements should the nurse include in the teaching? (Select all that apply)
A. By witnessing the signing of the informed consent form, the nurse is indicating that the client
voluntarily gave consent
B. A client who signs an informed consent form should understand the treatment plan
C. A client who signs an informed consent form should be competent
D. The nurse should disclose the purpose of the treatment before the client signs the consent
form
E. Signing the informed consent form indicates that the family agrees to the treatment options

Answer: A. By witnessing the signing of the informed consent form, the nurse is indicating that
the client voluntarily gave consent
B. A client who signs an informed consent form should understand the treatment plan
C. A client who signs an informed consent form should be competent
114. A nurse is preparing to insert an indwelling catheter for a female client. Identify the
sequence of actions the nurse should take
Answer:
1. Apply sterile gloves and place cleansing balls in antiseptic solution
2. Attach prefilled syringe to indwelling catheter inflation hub
3. Lubricate the catheter and place fenestrated drape over perineum
4. Cleanse the meatus with the dominant hand in a downward motion
5. Insert the catheter until a flow of urine begins
115. A nurse in a substance use unit spends an equal amount of time with each of his assigned
clients, even though some of the clients have committed serious crimes. Which of the following
ethical principles is the nurse demonstrating?
A. Justice
B. Autonomy
C. Nonmaleficence
D. Veracity
Answer: A. Justice
116. A nurse is assessing a client who has a magnesium level of 4.4 mEq/L. Which of the
following findings should the nurse expect?
A. Hypotension
B. Tachycardia
C. Muscle cramps
D. Hyperreflexia
Answer: A. Hypotension

117. A nurse is reviewing the medical record of a client who has a new prescription for
gentamicin. The nurse should identify that concurrent use with which of the following current
medications can increase the client's risk for ototoxicity?
A. Captropril
B. Metoprolol
C. Furosemide
D. Hydrochlorothiazide
Answer: C. Furosemide
118. A nurse is preparing to administer 2.5mL of medication intramuscularly to an adult client.
Which of the following is the safest site for the nurse to use?
A. Ventrogluteal
B. Dorsogluteal
C. Vastus lateralis
D. Rectus femoris
Answer: A. Ventrogluteal
119. A nurse is performing triage following a natural disaster. Which of the following clients
should the nurse identify as the highest priority to receive care?
A. A client who has agonal respirations
B. A client who has an open skull fracture and is unresponsive
C. A client who has a traumatic arm amputation
D. A client who has a fracture of the femur
Answer: C. A client who has a traumatic arm amputation
120. A nurse is caring for a group of clients. Which of the following clients should the nurse
assess first?
A. A client who has heart failure and reports shortness of breath while ambulating
B. A client who has abdominal pain and is vomiting coffee-ground emesis
C. A client who has benign prostatic hyperplasia and is unable to urinate
D. A client who had an open cholecystectomy and has green drainage from the T-tube

Answer: B. A client who has abdominal pain and is vomiting coffee-ground emesis
121. A charge nurse is providing teaching to a newly licensed nurse on how to clean surfaces
contaminated with blood. Which of the following agents should the nurse include in the
teaching?
A. Hydrogen peroxide
B. Isopropyl alcohol
C. Chlorine bleach
D. Chlorhexidine
Answer: C. Chlorine bleach
122. A nurse is planning care for a client who is experiencing acute mania. Which of the
following actions should the nurse include in the plan of care?
A. Provide a flexible activity schedule
B. Provide high-calorie nutritional supplements
C. Allow the client to eat meals alone in her room
D. Allow the client to choose her clothes independently
Answer: B. Provide high-calorie nutritional supplements
123. A nurse is reviewing the medical records of four clients. Which of the following
prescriptions correct documentation?
A. Atropine .4 mg IV stat
B. Lorazapam 1.0 mg IV PRN every 6 hr
C. Sucralfate 1 g PO hr ac
D. Enoxaparin 30 mg SC every 12 hr
Answer: D. Enoxaparin 30 mg SC every 12 hr
124. A nurse is performing a dressing change for a client who has a sacral wound using negative
pressure wound therapy. Which of the following actions should the nurse take first?
A. Determine the client's pain level
B. Irrigate the wound with 0.9% sodium chloride irrigation

C. Apply skin preparation to wound edges
D. Don sterile gloves
Answer: A. Determine the client's pain level
125. A nurse is assessing a client who is gravida 2, para 1. The client is at 41 weeks of gestation
and is receiving oxytocin for the augmentation of labor. The nurse should decrease the infusion
rate for which of the following findings?
A. Contractions are strong to palpation
B. Cervix is dilating at 1 cm every 4 hr
C. Consistent contractions last 80 seconds
D. Contractions occur every 90 seconds
Answer: D. Contractions occur every 90 seconds
126. A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased
blood pressure. The nurse should identify that these findings are potential manifestations of
which of the following?
A. Cannabis withdrawal
B. Opioid intoxication
C. Amphetamine intoxication
D. Alcohol withdrawal
Answer: B. Opioid intoxication
127. A nurse in a postpartum unit is caring for several clients. After receiving a change of shift
report, which of the following clients should the nurse assess first?
A. A client who is 2 days postpartum and whose fundus is 2 fingerbreadths below the umbilicus
B. A client who is 1 day postpartum and has not voided in 8 hr
C. A client who is 3 days postpartum and has not had a bowel movement since prior to admission
D. A client who is 4 days postpartum and has lochia serosa
Answer: C. A client who is 3 days postpartum and has not had a bowel movement since prior to
admission

128. A nurse is precepting a nursing student who brings the following client observations to the
nurse's attention. Which of the following clients should the nurse assess first?
A. A client who is 3 hr post foley catheter removal and has not voided
B. A client who is 3 days postoperative colectomy with a large, loose melena stool
C. A client who is 1 day postoperative total hip replacement with a pain level of 7 on a scale of 0
to 10
D. A client who is coughing up pink-tinged sputum following a bronchoscopy and lung biopsy 1
hr ago
Answer: D. A client who is coughing up pink-tinged sputum following a bronchoscopy and lung
biopsy 1 hr ago
129. A nurse manager is reviewing documentation standards with a group of newly licensed
nurses. Which of the following statements should the nurse manager include in the teaching?
A. Include the complete name of the medication morphine sulphate
B. Do not use a leading zero prior to a decimal point
C. Write the letter U when noting the dosage of insulin
D. Use the abbreviation QOD when indicating every other day
Answer: A. Include the complete name of the medication morphine sulphate
130. A nurse is caring for a client following insertion of a subclavian nontunneled percutaneous
central venous catheter. The provider writes a prescription to initiate an IV infusion of Ringer's
lactate at 150 mL per hr. Prior to starting the infusion, which of the following actions should the
nurse take?
A. Apply oxygen at 3 L/min per nasal cannula
B. Review the chest x-ray report
C. Flush the catheter with sterile water
D. Obtain a peripheral blood glucose level
Answer: B. Review the chest x-ray report
131. A nurse is planning care for a newly admitted client. Which of the following interventions
should the nurse plan to take first?

A. Initiate an IV access for the client
B. Administer pain medication to the client
C. Send the client to radiology for a CT scan
D. Insert an NG tube for the client
Answer: B. Administer pain medication to the client
132. A community health nurse is performing a vision screening on a 4 month old infant. When
shining a light source into the infant's visual field, which of the following is an expected finding?
A. The infant's eyes turn toward the light
B. The infant's head turns away from the light
C. The infant's eyes remain focused toward the floor
D. The infant closes their eyes
Answer: D. The infant closes their eyes
133. A nurse is monitoring a client during an IV urography procedure. Which of the following
client reports is the priority finding?
A. Metallic taste in mouth
B. Abdominal fullness
C. Feeling flushed and warm
D. Swollen lips
Answer: D. Swollen lips
134. A nurse is reviewing the history and physical of a client who has right ventricular heart
failure. Which of the following is an expected finding?
A. Crepitus
B. Elevated pulmonary artery pressure
C. Hepatosplenomegaly
D. Confusion
Answer: C. Hepatosplenomegaly

135. A nurse is teaching a client and their family about home hospice care. Which of the
following information should the nurse include in the teaching?
A. Hospice care improves quality of life through palliative care
B. Hospice care provides 24 hr, in home care
C. Hospice care is intended to postpone death
D. Hospice care encourages the family to coordinate health care services
Answer: A. Hospice care improves quality of life through palliative care
136. A nurse is preparing to administer eye drops to a client. Which of the following nursing
actions is appropriate?
A. Have the client tilt her head slightly so that the medication enters the nasolacrimal duct
B. Gently wash away any exudate along the eyelid margin from the outside towards the inner
canthus
C. Use aseptic technique and drop the medication into the conjunctival sac
D. Drop prescribed number of drops onto the cornea
Answer: C. Use aseptic technique and drop the medication into the conjunctival sac
137. A nurse suspects another nurse is chemically impaired during their shift. Which of the
following is an appropriate action for the nurse to take?
A. Report to the nurse manager
B. Set up a time to meet with the nurse
C. Assume care of the nurse's assigned clients
D. Ask another staff nurse to confirm the suspicion
Answer: A. Report to the nurse manager
138. A nurse is providing teaching to an adolescent client who has cystic fibrosis and has a
prescription for pancrelipase. Which of the following should the nurse include in the teaching?
A. Take on an empty stomach
B. Take 1 hr before meals
C. Take 1 hr after meals
D. Take with meals

Answer: D. Take with meals
139. A nurse manager is presenting information to the nursing staff regarding the appropriate use
of client restraints. Which of the following should the nurse include? (Select all that apply)
A. The provider should renew the prescription for restraints every 48 hr
B. The nurse should pad the bony prominences
C. The nurse should tie the restraints using a square knot
D. The nurse should remove the restraints every 2 hr
E. The provider's prescription should include the type of restraint to use
Answer: B. The nurse should pad the bony prominences
D. The nurse should remove the restraints every 2 hr
E. The provider's prescription should include the type of restraint to use
140. A nurse is preparing a client for surgery and has just administered the preoperative injection.
Which of the following actions should the nurse take?
A. Take the client to the bathroom to void
B. Ask the client to verify the surgical site
C. Review deep breathing and coughing exercises
D. Raise the side rails on the bed
Answer: D. Raise the side rails on the bed
141. A nurse is teaching the guardian of an infant who has developmental dysplasia of the hip
about a Pavlik harness. Which of the following instructions should the nurse include?
A. Adjust the straps on the harness once per week
B. Use only ultra-thin diapers applied over the straps
C. Maintain the child in a prone position while the harness is in place
D. Gently massage the skin under the straps once per day
Answer: D. Gently massage the skin under the straps once per day

142. A charge nurse is teaching a group of unit nurses about the policy for clients who have a
history of methicillin-resistant Staphylococcus aureus. Which of the following information
should the nurse include?
A. A client who has a history of MRSA will need antibiotics
B. A client who has a history of MRSA can develop immunity to the infection
C. A client who has a history of MRSA requires a protective environment
D. A client who has a history of MRSA can still transmit the infection
Answer: D. A client who has a history of MRSA can still transmit the infection
143. A nurse manager at a public health clinic is concerned about the rising number of sexually
transmitted infections in the community. The purpose of which of the following is to generate
new ideas to address the public health concern?
A. A brainstorming session with nurses
B. A community-wide program
C. Role playing with nurses
D. Personal discussions with clients
Answer: A. A brainstorming session with nurses
144. A nurse is checking laboratory results for a client. Which of the following laboratory
findings indicates hypervolemia?
A. Serum calcium 10 mg/dL
B. Urine specific gravity 1.001
C. Serum sodium 138 mEq/L
D. Urine pH 6
Answer: B. Urine specific gravity 1.001
145. A nurse is teaching a group of farmworkers who work with pesticide about minimizing
exposure. Which of the following information should the nurse include in the teaching?
A. Change clothes after working in the field
B. Apply petroleum jelly to the nostrils prior to working in the field
C. Wipe fruits and vegetables from the field with a dry cloth before consuming

D. Take a hot shower 1 hr after finishing work
Answer: A. Change clothes after working in the field
146. A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions
should the nurse take?
A. Monitor for abdominal ascites
B. Implement a low-carbohydrate diet
C. Review serum amylase levels
D. Place warm compresses on area of pruritus
Answer: A. Monitor for abdominal ascites
147. A nurse is giving discharge instructions to a client who has a new ileostomy. The nurse
should recognize that the teaching has been effective when the client states,
A. My stoma size will stay the same, even after it has healed
B. My stoma will drain liquid fluid continuously
C. I will change my pouch system every 2 weeks
D. I will ensure that my medications are enteric coated
Answer: B. My stoma will drain liquid fluid continuously
148. A nurse is planning care for a client who is postoperative following creation of an
arteriovenous fistula in the left arm. Which of the following actions should the nurse include in
the plan?
A. Auscultate the client's left arm for a bruit every 4 hr
B. Compare blood pressure in both arms every 2 hr
C. Instruct the client to keep the left arm in a dependent position
D. Encourage the client to restrict movement of the left arm
Answer: A. Auscultate the client's left arm for a bruit every 4 hr
149. A nurse is caring for a client who has a new prescription for lithium carbonate. Prior to
administering the first dose, which of the following laboratory values should the nurse evaluate?
A. Arterial blood gases

B. Total cholesterol
C. Thyroid hormones
D. Haemoglobin
Answer: C. Thyroid hormones
150. A nurse is caring for an infant who is being treated for dehydration. Which of the following
findings indicates the treatment is effective?
A. Flat anterior fontanel
B. Oliguria
C. Oral intake of 4 oz every 3 hr
D. Capillary refill 4 seconds
Answer: A. Flat anterior fontanel
ATI Version B
1. A nurse is providing teaching about sumatriptan to a client. Which of the following statements
by the client indicates an understanding of the teaching?
Answer: b. "I will take this medication at the onset of a migraine."
2. A nurse is caring for a client who has a new diagnosis of Chlamydia trachomatis. Which of the
following actions should the nurse take?
Answer: a. Report the infection to the state department of health
3. A nurse teaching a client who has new diagnosis of diabetes mellitus about foot care. Which of
the following instructions should the nurse include in teaching?
Answer: c. Wear clean cotton socks every day (prevent bacteria )
4. A nurse is planning to delegate task to an assistive personnel (AP). Which of the following
tasks should the nurse assign to the AP?
Answer: d. Record a client's blood pressure reading by 1000 (delegation rights timeframe)

5. A nurse is caring for a client who is at 20 weeks of gestation and reports urinary frequency.
Which of the following actions is appropriate?
Answer: d. Obtain a specimen for culture and sensitivity
6. A nurse is preparing to administer several medications through a client's nasogastrointestinal
tube. The nurse should ask the pharmacist about the availability of a different form for which of
the following medications?
Answer: c. Enteric-coated aspirin ( because the drug can only be broken done with enzymes in
the intestine only)
7. A nurse is caring for a client who has prescriptions for furosemide and gentamicin. For which
of the following complications should the nurse monitor the client?
Answer: b. Ototoxicity
8. A nurse is teaching a parent of a school-age child who is to begin a daily dose of
methylphenidate. Which of the following should the nurse include in the teaching?
Answer: d. "You should administer the medication after breakfast." (this med cuts children's
appetite and stimulates the child to focus)
9. A nurse is providing dietary teaching to a client who has heart failure. Which of the following
recommendations is appropriate for this client?
Answer: c. Encourage seasoning with dry herbs
10. A nurse is reviewing legal issues in healthcare with a group of newly licensed nurses. Which
of the following recommendations should the nurse make?
Answer: d. Obtain personal professional liability insurance coverage (malpractice insurance is a
must for new nurses)
11. A nurse is caring for an infant who is in contact isolation and received a blood transfusion.
Which of the following actions is appropriate for the nurse to take to provide cost-effective care?

Answer: d. Bring in formula as needed (to avoid waste; patient on contact isolation, if you bring
a lot in and don't use it you will have to waste the formula)
12. A nurse is caring for a preschool child who is dehydrated. Which of the following assessment
findings indicates moderate dehydration?
Answer: b. Oliguria (little urine)
13. A nurse is developing a plan of care for an older adult client who has hearing loss. Which of
the following instructions should the nurse include in the plan?
Answer: a. Rephrase statements that the client misunderstands
14. A nurse has received clearance to go back to works after an occupational injury to her back.
To reduce the risk of future lifting injuries, which of the following principles should the nurse
when lifting objects?
Answer: c. Keep the object close to her body as she lifts it. (bend at the knees)
15. A nurse is collaborating with social services in the discharge planning for a young adult client
who is below the poverty income level and will require home IV therapy. Which of the following
resources should the nurse recommend? (Select all that apply).
Answer: b. Food stamps d. Medicaid
16. A nurse is assessing a client who receiving a Mantoux skin test 72 hr ago for tuberculosis
screening. Which of the following findings indicates a positive test result?
Answer: b. An elevated, hardened area
17. A nurse is planning care for a group of clients. Which of the following methods should the
nurse use to manage time effectively?
Answer: b. Gather supplies prior to completing a dressing change
18. A nurse is providing care for a client following a thoracentesis. If the client develops a
pneumothorax, which of the following assessment findings should the nurse expect?

Answer: b. Pain on inhalation
19. A nurse is caring for a client who is 2 hr postoperative following a cardiac catheterization.
Which of the following is the priority assessment finding?
Answer: b. Absence of pedal pulse in the affected extremity
20. A charge nurse is providing teaching to a newly licensed nurse about acceptable client
identifiers before administering indications. Which of the following statements by the newly
licensed nurse requires intervention?
Answer: c. "I should check the client's room number prior to giving medication."
21. A charge nurse is orienting a newly licensed nurse to the telemetry unit. Which of the
following should the charge nurse identify as the purpose of telemetry monitoring?
Answer: c. To identify dysrhythmias
22. A nurse is caring for a client who has bipolar disorder. Which of the following client findings
is an indication that the client is about to experience a manic phase?
Answer: c. The client is restless and has changes in his sleep pattern
23. A nurse is teaching a client who has atrial fibrillation and its start taking dabigatran. Which of
the following statements by the client indicates an understanding of the teaching?
Answer: d. "I should keep the medication in the original container"
24. A nurse is planning care for a client who follows Buddhist dietary practices. Which of the
following food selections should the nurse recommend for the clients meal tray?
Answer: d. Spinach and strawberry salad
25. A nurse in a long-term care facility is caring for an older adult client who has dementia. The
client believes he needs to get ready for work and is becoming increasingly agitated. Which of
the following actions should the nurse take?
Answer: a. Assist the client in selecting clothing for the day (distract patient)

26. A nurse is caring for a client who has a prescription for a peripheral IV catheter. After
puncturing the skin with the vascular access device and noting a blood return in the flashback
chamber, which of the following actions should the nurse perform next?
Answer: Advance the catheter into the vein
27. A nurse in an emergency department is planning care for a client who has abdominal trauma
from a motor-vehicle crash. Which of the following provide prescriptions should the nurse
implement first?
Answer: c. Place a large-bore IV catheter in an upper extremity
28. A nurse in a family health clinic is caring for a client who requests information regarding the
correct use of condoms. Which of the following statements should the nurse make?
Answer: d. "When using implanted contraceptive methods, condoms should also be used to
protect against STDs"
29. A nurse is admitting a client who has dementia to a long-term care facility. The client tells the
nurse that she lived in this facility years ago and took care of all the residents by herself. The
nurse should document this as which of the following findings?
Answer: d. Confabulation
30. A nurse is admitting a client who is to undergo paracentesis for removal of ascitic fluid.
Which of the following actions should the nurse take?
Answer: d. Weigh the client before and after the procedure
31. A nurse is caring for a client following a gastric resection. The client experience cramping, an
increased pulse rate, dizziness and nausea after eating a meal. Which of the following
instructions should the nurse provide to the client?
Answer: c. Drink liquids at least 1 hr or after meals

32. A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The
nurse should recognize which of the following as an indication that the medication has been
effective?
Answer: c. Weight loss
33. A nurse is providing prenatal teaching for a client who has herpes simplex virus. Which of
the following client statements indicates an understanding of the teaching?
Answer: c. "I should have a caesarean delivery if I'm having an outbreak"
34. A nurse is providing an in-service about client evacuation during a fire. Which of the
following clients should the nurse instruct the staff to evacuate first?
Answer: b. A client who is ambulatory and receiving oxygen
35. A nurse is teaching the family of an infant who has decreased cardiac output due to
congenital heart disease. Which of the following instructions should the nurse include in the
teaching?
Answer: c. Observe for manifestations of hunger in order to feed the infant before crying occurs
36. A nurse is caring for a client who states that the first day of her menstrual period was June 14.
Using Nagele's rule, the nurse should calculate the client's estimated date of delivery as which of
the following?
Answer: c. March 21
37. A nurse in the intensive care unit is planning care for a client who has closed head injury. The
client's intracranial pressure (ICP) is being monitored via an intraventricular catheter. Which of
the following actions should the nurse include in the plan of care?
Answer: d. Avoid overstimulation of the client
38. A nurse is reviewing the medical records of four clients. The nurse should identify that which
of the following client findings requires follow up care?
Answer: b. A client who received a Mantoux test 48 hr ago and has an irritation

39. A nurse is caring for a client who is alert and oriented and is receiving continuous ECG
monitoring. The cardiac rhythm strip shows a wavy baseline, so distinguishable P waves, and an
increased heart rate. The nurse should identify the cardiac rhythm as while of the following?
Answer: b. Atrial fibrillation
40. A nurse is preparing to document care in a client's electronic health record. Which of the
following entries by the nurse demonstrates appropriate documentation?
Answer: c. "Client has a heart rate of 102/min"
41. A nurse is providing discharge instructions to a client who is 1-day postoperative following a
vertical banded gastroplasty for morbid obesity. Which of the following statements demonstrates
an understanding of the dietary teaching?
Answer: a. "Vomiting is common and I will have to learn to live with it. –
42. A nurse is positioning a client for caesarean birth. To prevent a compromise in placental
blood flow during the intraoperative period, which of the following actions should the nurse take.
Answer: b. Place a wedge under one of the client's hips ( supine is contraindicated with pregnant
women)
43. A nurse is caring for a client who asks for information regarding organ donation. Which of
the following responses should the nurse make?
Answer: c. "Your desire to be an organ donor must be documented in writing"
44. A nurse is completing an admission assessment for a client who has narcissistic personality
disorder. Which of the following findings should the nurse expect?
Answer: d. Preoccupied with aging
45. A nurse is admitting a client who has been taking prednisone 10 mg PO daily for 10 months.
Which of the following assessment findings should the nurse identify as an adverse effect of this
medication therapy?

Answer: c. Thin extremities with obesity of the abdomen (s/s of Cushing)
46. A nurse is teaching a client about a variety of stress management techniques. Which of the
following instructions by the nurse is appropriate?
Answer: b. Tighten your muscles before relaxing them when using muscle relaxation
techniques"
47. A charge nurse is delegating care for a group of clients. Which of the following tasks should
the charge nurse assign to a licensed practical nurse?
Answer: d. Perform a sterile dressing change for a client who has an abdominal wound
48. A community health nurse is planning a program to address substance use in the adolescent
population. Which of the following interventions should the nurse include as a method of
secondary prevention?
Answer: b. Establish an early detection program for substance use (screening)
49. A charge nurse is observing a conflict between two nurses who both insist that the charge
nurse Favors the other when making assignments. Which of the following conflict-resolution
strategies should the charge nurse use?
Answer: c. Encourage collaboration between the two nurses when making the assignments
50. A nurse is planning care for a client who has cancer and is about to receive low dose
brachytherapy via a vaginal implant applicator. Which of the following interventions should the
nurse include in the plan of care?
Answer: b. Insertion of an indwelling urinary catheter
51. A nurse is caring for a client who has received a first dose of losartan. Which of the following
adverse effects should the nurse report to the provider immediately?
Answer: c. Angioedema

52. A nurse is assessing a client who is taking clozapine. For which the following adverse effects
should the nurse monitor and report to the provider?
Answer: c. Sore throat
53. A nurse is caring for a client who has a spinal cord injury. Which of the following support
devices should the nurse plan to use to prevent plantar flexion contractures?
Answer: d. Footboard (to avoid foot drop)
54. A nurse is caring for four clients. Which of the following client data should the nurse report
to the provider?
Answer: c. A client who has a prescription for chemotherapy and an absolute neutrophil count of
75/mm3
55. A nurse is evaluating the outcomes for a client who has had an amnioinfusion for
oligohydramnios. Which of the following findings indicates an adverse response to this
treatment.
Answer: c. Uterine contractions
56. A nurse is caring for a client who is 2 hr postpartum. The client states, I'm having difficulty
emptying my bladder." Which of the following actions should the nurse take?
Answer: b. Pour warm water from a squeeze bottle over the client perineum
57. A nurse is caring for a client who has had gastric bypass surgery 1 week ago and has
manifestations of early dumping syndrome. Which of the following findings should the nurse
expect? (Select all the apply.)
Answer: a. Diaphoresis b. Syncope, Dizziness
58. A nurse is assessing a client who has a stage IV pressure ulcer and is undergoing treatment
prescribed by a wound care consultant. For which of the following findings should the nurse
contact the consultant to revise the plan of care?
Answer: d. Weight loss of 5% in 10 days

59. A nurse is caring for a male client who has a spinal cord injury. Which of the following
techniques should the nurse use when providing perineal care?
Answer: c. Discard the washcloth after cleansing the urethral meatus.
60. A nurse in a family practice clinic is screening an adolescent client for idiopathic scoliosis.
Which of the following assessments should the nurse perform as part of the screening?
Answer: b. Measure the truncal rotation
61. A nurse in a mental health facility received change-of-shift report for four clients. Which of
the following clients should the nurse plan to assess first?
Answer: a. A client placed in restraints due to aggressive behavior
62. A nurse is caring for a client who is receiving intravenous antibiotics every 6 hr. Which of the
following responses by the client is the priority for the nurse to evaluate?
Answer: b. "My throat feels tight" (allergic sign)
63. A nurse is caring for a client who has a 22-gauge IV inserted 2 days ago and as new
prescription for 2 units of packed RBCs. Which of the following actions should the nurse take?
Answer: d. Place a larger gauge IV in the opposite extremity (2 units is a lot)
64. A nurse is providing discharge teaching to the partner of a client who has a tracheostomy.
Which of the following information should the nurse include in the teaching?
Answer: b. How to operate the portable suction machine
65. A nurse is caring for a client who requires seclusion to prevent harm to others on the unit.
Which of the following is an appropriate action for the nurse to take?
Answer: c. Discuss with the client his inappropriate behavior prior to seclusion
66. A nurse is teaching a group of parents about expected development of gross motor skills
during infancy. The nurse should teach that the following developmental tasks are expected to

occur in what order? (Move the steps into the box on the right, placing them in the selected order
of performance)
Answer: c. Rolls from back to side
d. Rolls from back to abdomen
b. Sits steadily unsupported
a. Changes from prone to sitting
67. A nurse is speaking with a family member of a client who has a terminal diagnosis. The
family member states, "I'm having a hard time letting her go." The nurse should recognize that
the family member is experiencing which of the following types of grief?
Answer: a. Anticipatory
68. A nurse is providing discharge teaching to a client who has chronic kidney disease and is
receiving haemodialysis. Which of the following instructions should the nurse include in the
teaching?
Answer: c. Dispose of recapped needles and syringes in a biohazard bag
69. A nurse is preparing to administer methylprednisolone sodium succinate to a client who has
chronic inflammatory disorder. The nurse should plan to monitor which of the following
laboratory test while the client is taking this medication?
Answer: b. Serum glucose
70. A nurse is discharging a client who has a colostomy. The client states that she would like to
use her moisturizing soap to clean around the stoma. Which of the following responses by the
nurse is appropriate?
Answer: a. "Lubricants in moisturizing soaps can interfere with adhesion of the appliance"
71. A nurse is caring for a client who has central venous catheter and develops an air embolism.
Which of the following actions should the nurse take?
Answer: d. Place the client in a left-lateral Trendelenburg position

72. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The abg has 20
mL remaining to infuse but a new bag is not readily available. Which of the following actions
should the nurse take?
Answer: c. Administer dextrose 10% in water
73. A nurse is assessing a client who has been taking oral contraceptive for the past 6 months.
Which of the following findings should the nurse immediately report to the provider?
Answer: d. Persistent headache
74. A nurse is caring for a client who has a new diagnosis of schizophrenia and a prescriptions
for an antipsychotic medication. The nurse should recognize that which of the following
indicates an adverse effect that must be reported to the provider?
Answer: a. The client is observed displaying a shuffling gait while walking in the hall
75. A nurse manager on an interprofessional team is creating a disaster plan. The nurse should
include in the plan that which of the following actions is the responsibility of the unit nurse
during a disaster?
Answer: a. Recommend to the provider a list of client for early discharge.
76. A nurse is assessing a client who has antisocial personality disorder. Which of the following
characteristics should the nurse expect?
Answer: d. Lack of remorse
77. A nurse is an emergency department is reviewing the laboratory results of a client who has
salicylism. The client's ABG values are pH and HCO3- 24. The nurse should identify and report
to the provider that the client has which of the following acid-base imbalances?
Answer: d. Respiratory alkalosis
78. A nurse is admitting a client to a medical-surgical unit. When performing medication
reconciliation for the client, which of the following actions should the nurse take?

Answer: b. Compare new prescriptions with the list of medications the client reports (for
polypharmacy)
79. A nurse is providing a care for a group of clients. Which of the following clients should the
nurse assess first?
Answer: d. A client who has a fractured tibia and reports shortness of breath
80. A nurse is caring for a client who has a chest tube drainage device. Which of the following
findings indicates to the nurse the presence of an air leak?
Answer: d. Continuous bubbling in the water seal chamber
81. A nurse in an emergency department is caring for a client who is having manifestations of an
ischemic stroke that began 2 hours ago. Which of the following actions should the nurse take?
Answer: d. Initiate fibrinolytic therapy
82. A nurse is obtaining a blood specimen from a client who has a peripherally inserted central
catheter. Which of the following actions should the nurse take?
Answer: a. Flush with 20 mL of 0.9% sodium chloride after obtaining the blood sample
PROPER BODY MECHANICS Q'S WITH PICTURES
83. A nurse is assessing a young adult male client who reports having an unusual rash on the
palms of his hands and bottom of his feet. The nurse should further assess for which for the
following infections?
Answer: d. Syphilis
84. A nurse in the emergency department is interviewing a client immediately following a sexual
assault. Which of the following actions should the nurse take first?
Answer: c. Determine the client's current anxiety level
85. A nurse is caring for a client who has a vented NG tube set to low intermittent suction and
has vomited. Which of the following actions should the nurse perform first?

Answer: a. Provide oral hygiene
86. Appendicitis pain
Answer: RLQ (McBurney's Point)
87. A nurse is caring for a client who has a history of depression and is experiencing crisis.
Which of the following actions should the nurse take first?
Answer: a. Confirm the client's perception of the event.
88. A nurse is preparing discharge information for a client who has type 2 diabetes mellitus.
Which of the following information resources should the nurse provide the client?
Answer: d. Food exchange lists for meal planning from the American Diabetes Association
89. A nurse is administering medications to group of clients. Which of the following occurrences
requires the completion of an incident report?
Answer: a. A client receives his antibiotic 2 hour late
90. A charge nurse is concerned about a recent increase in facility- acquired infections. Which of
the following actions should the nurse take first?
Answer: c. Identify possible precipitating factors related to the infections
91. A nurse is planning teaching for a client who has a newly impaired implantable
cardioverter/defibrillator. Which of the following information should the nurse include?
Answer: a. Wear loose-fitting clothing
92. A nurse is receiving change of shift report from the nurse on the previous shift. Which of the
following information should the nurse include in the report?
Answer: b. Client in room 303 needs his 8 am glucose taken before his scheduled insulin."
93. A nurse is caring for a preschool-age child who has injuries due to abuse by her father’s
partner. Which of the following actions by the nurse is appropriate?

Answer: a. Interview the child about the abuse with the father present.
94. A nurse is caring for a client who speaks a different language than the nurse and is using an
interpreter. Which of the following actions should the nurse take when working with the
interpreter?
Answer: b. Speak in normal voice at natural pace
95. A nurse manager is planning a staff in service to address advocacy in client care. The nurse
should promote which of the following practices during the in service? (Select all of that apply)
Answer: a. promoting health care access
d. addressing client needs when providing resources
e. encouraging clients to seek further information from the provider
96. A nurse is caring from a client who has prescription for lactated Ringers IV 4,080 mL/24hr.
The nurse should set the IV infusion pump to deliver how many mL/hr to administer half the
total volume in the first 8 hour? (Round answer to the nearest whole number. Use a leading zero
if it applies. Do not use a trailing zero.)
Answer: a. 255ml/hr (4080 / 2; 2040/8 = 255ml/hr)
97. A nurse is planning care for a client who is in labor and gonorrhoea. Which of the following
actions should the nurse include in the plan for delivery?
Answer: b. Instil erythromycin ointment into the newborns eyes
98. A nurse is providing teaching to a parent of a child who has varicella. Which of the following
statements should the nurse include in the teaching?
Answer: c. "Your child can return to school once the lesions have crusted over."
99. A nurse is planning care for a client who has stage II Parkinson's disease. Which of the
following actions should the nurse include in the plan of care?
Answer: ac

100. A nurse is assessing a toddler whose parent is concerned about the child's hearing ability.
Which of the following findings indicates the need for further hearing evaluation?
Answer: a. Uses gestures to communicate
101. A nurse is providing discharge teaching about car seat safety to a parent of a newborn.
Which of the following statements by the parent indicates an understanding of the teaching?
Answer: d. "I will position my baby at 45-degree angle in the car seat."
102. A nurse is teaching an adolescent who has type 1 diabetes mellitus and his parents how to
dispose of his insulin syringes and needles at home. Which of the following instructions is
appropriate?
Answer: b. Place the needles in an aluminium coffee can and store them on a high shelf
103. A nurse is preparing to administer Cefpodoxime 10 mg/kg/day PO divided equally every 12
hours to a child who weighs 66 lb. available is Cefpodoxime 20 mg/mL oral solution. How many
mL should the administer per dose? (Round the answer to the nearest tenth. Use a leading zero if
applicable. Do not use a trailing zero.)
Answer: a. 7.5mL
104. A nurse is providing teaching about crutch safety to a client. Which of the following clients
actions indicates an understanding of the teaching?
Answer: c. The client keeps her axillae free of pressure
105. A nurse in a clinic is assessing a 6-month old infant. Which of the following findings should
the nurse report to the provider?
Answer: b. Closed anterior fontanel
106. A nurse is caring for a toddler who has cancer and is experiencing stomatitis from
chemotherapy. Which of the following interventions should the nurse implement?
Answer: c. Provide soft, non-acidic foods

107. A nurse is receiving report on four postpartum clients. Which of the following clients should
the nurse plan to attend to first?
Answer: a. A client who has hyperreflexia while receiving magnesium sulphate
108. A nurse is caring for a client who has a new prescription for Clozapine. Which of the
following should the nurse recognize as an adverse effect of this medication?
Answer: c. Agranulocytosis
109. A nurse is teaching a client who has a new prescription for an MAOI. which of the
following foods is contraindicated with this medication?
Answer: c. Cheese
110. A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the
following findings indicates that the child may be experiencing haemorrhage?
Answer: a. Frequent swallowing
111. A nurse is providing preoperative teaching to an older adult female client who is scheduled
for a laminectomy and uses supplements, which of the following supplements should the nurse
identify as increasing the client's risk for hypotension during pregnancy?
Answer: c. Black cohosh
112. A nurse is preparing an in service for a group of nurses about malpractice issues in nursing.
Which of the following examples should the nurse include in the teaching?
Answer: c. Administering potassium IV bolus
113. A nurse is caring for a 3 month old infant who has gastroenteritis and is receiving
monitoring for dehydration. For which of the following findings should the nurse monitor?
Answer: b. Weight loss

114. A nurse is caring for a client who has end stage kidney disease. The clients adult child ask
the nurse about becoming a living kidney donor for her father. Which of the following conditions
in the child's medical history should the nurse identify as a contraindication to the procedure?
Answer: c. Hypertension
115. A nurse is providing teaching to a client who is at 14 weeks gestation about findings to
report to the provider. Which of the following findings should the nurse include in the teaching?
Answer: a. swelling of the face
116. A nurse is reviewing laboratory values for a client who has bipolar disorder and takes
lithium carbonate. Which of the following values should the nurse report to the provider?
Answer: b. Thyroxine (t4) 2.8 mcg/dL
117. A nurse is preparing to perform a sterile wound irrigation and dressing change for a client.
Which of the following actions by the nurse indicates a break in surgical aseptic technique?
Answer: b. Balancing the bottle on the sterile basin while pouring the liquid
118. A school nurse is performing scoliosis screenings. The nurse should recognize which of the
following clinical manifestations as an indication of scoliosis?
Answer: a. Uneven shoulder pelvic heights
119. A nurse is providing teaching to a client who has diabetes mellitus about the glycosylated
haemoglobin blood test. Which of the following statements by the client indicated an
understanding of this test?
Answer: d. "I will use this test to monitor how well I control my blood levels."
120. A nurse on a med surg unit is planning care for a group of clients. Which of the following
clients should the nurse plan to see first?
Answer: a. A client who has heart failure and an oxygen saturation level of 89%

121. A nurse is planning care for a child who has neutropenia due to leukaemia. Which of the
following interventions should the nurse include in the plan of care?
Answer: a. Screen the child's visitors for active infections
122. A nurse is evaluating a client understanding of food nutrition labels. Which of the following
statements by the client indicates an understanding of the teaching?
Answer: d. "The ingredient with the greatest weight appears first."
123. A nurse is providing discharge teaching to a client who has hyperlipidaemia and is is to start
treatment with atorvastatin. The nurse should instruct the client to avoid taking the medication
with which of the following?
Answer: d. Grapefruit juice
124. A nurse in a clinic is caring for an adolescent client who is at 24 weeks gestation and
showing signs of preeclampsia. Which of the following findings should the nurse expect?
Answer: d. Increased protein in urine
125. A charge nurse is teaching a newly licensed nurse about designating a health care proxy in
situations that requires a durable power of attorney for a health care (DPAHC). Which of the
following information should the charge nurse include?
Answer: c. "The proxy can make treatment decisions if the client is under anesthesia."
126. A nurse is assigning client care tasks to an assistive personnel for the upcoming shift. Which
of the following tasks is within the AP's the scope of practice?
Answer: a. Perform cardiopulmonary resuscitation on a client
127. A nurse on a med surg unit is receiving report for four clients. Which of the following
clients should the nurse assess first?
Answer: b. A client who is receiving a blood transfusion and reports low back pain (indicates
transfusion reaction)

Review C 1
1. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The
nurse should monitor the client for which of the following complications?
A. Vomiting
B. Hypertension
C. Epigastric pain
D. Contractions
Answer: D. Contractions
2. A nurse is providing teaching to an older adult client about methods to promote nighttime
sleep. Which of the following instructions should the nurse include?
A. Stay in bed at least 1 hr if unable to fall asleep
B. Take a 1 hr nap during the day
C. Perform exercises prior to bedtime
D. Eat a light snack before bedtime
Answer: D. Eat a light snack before bedtime
3. A nurse on a telemetry unit is caring for a client who becomes unconscious and whose monitor
displays ventricular tachycardia. Which of the following actions should the nurse take first after
determining the client does not have a palpable pulse?
A. Assess heart sounds
B. Defibrillate
C. Establish IV access
D. Administer epinephrine
Answer: B. Defibrillate
4. A nurse is admitting a client who 1 week postpartum and reports excessive vaginal bleeding.
The nurse does not speak the same language as the client. The client's partner and 10-year-old
child are accompanying her. Which of the following actions should the nurse take to gather the
client's admission data?

A. Have the client's child translate
B. Allow the client's partner to translate
C. Request a female interpreter through the facility
D. Ask a nursing student who speaks the same language as the client to translate
Answer: C. Request a female interpreter through the facility
5. A nurse is caring for a client who is febrile. To reduce the client's fever, the nurse applies a
cooling blanket. Which of the following findings indicates the client is having an adverse
reaction to the cooling?
A. Flushing
B. Tachycardia
C. Restlessness
D. Shivering
Answer: D. Shivering
6. A nurse is caring for a client who has deep-vein-thrombosis of the left lower extremity. Which
of the following actions should the nurse take? (Exhibit)
A. Position the client with the affected extremity lower than the heart
B. Withhold heparin IV infusion PTT- 30-40 seconds; x2 if on heparin
C. Administer acetaminophen
D. Massage the affected extremity every 4 hr
Answer: B. Withhold heparin IV infusion PTT- 30-40 seconds; x2 if on heparin
7. A nurse is reviewing assessment data from several clients. For which of the following clients
should the nurse recommend referral to a dietitian?
A. An older adult client who has a BMI of 24
B. A client who has a nonhealing leg ulcer
C. An older adult client who has presbyopia
D. A client who has an albumin level of 3.7 g/dL (normal 3.4-5.4)
Answer: B. A client who has a nonhealing leg ulcer

8. A nurse is providing discharge teaching to a client who has a chronic kidney disease and is
receiving haemodialysis. Which of the following instructions should the nurse include in the
teaching?
A. Eat 1 g/kg of protein per day
B. Take magnesium hydroxide for indigestion
C. Drink at least 3 L of fluid daily
D. Consume foods high in potassium- restrict
Answer: A. Eat 1 g/kg of protein per day
9. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the
following places the client at risk for aspiration?
A. Sitting in a high-Fowler's position during the feeding
B. A history of gastroesophageal reflux disease
C. Receiving a high osmolarity formula
D. A residual of 65 mL 1 hr postprandial?
Answer: B. A history of gastroesophageal reflux disease
10. A nurse is providing prenatal teaching to a client who is at 12 weeks of gestation. The nurse
should tell the client that she will undergo which of the following screening tests at 16 weeks of
gestation?
A. Chorionic villus sampling- as early as 8 weeks
B. Cervical cultures for chlamydia- 1st appointment.
C. Nonstress test -28 weeks
D. Maternal serum alpha-fetoprotein- 16 to 18 weeks
Answer: D. Maternal serum alpha-fetoprotein- 16 to 18 weeks
11. A nurse is caring for a client who is on bed rest. The nurse should recognize that which of the
following findings is a complication of immobility?
A. Decreased serum calcium levels- increased serum calcium
B. Increased blood pressure- hypotension
C. Swollen area on calf

D. Urinary frequency
Answer: C. Swollen area on calf
12. A nurse in acute care mental health facility is participating in a medication-education group.
The leader of the group uses a laissez-faire leadership style. Which of the following actions
should the nurse expect from the leader during the session?
A. The leader encourages group members to remain silent until questions are called for
B. The leader lecture about medication adverse effects to the group members
C. The leader allows the group to discuss whatever they would like to regarding their
medications
D. The leader has group members vote on what they would like to learn about during the session
Answer: D. The leader has group members vote on what they would like to learn about during
the session
13. A nurse is providing teaching about digoxin administration to the parents of a toddler who
has heart failure. Which of the following statements should the nurse include in the teaching?
A. "You can add the medication to a half-cup of your child's favourite juice."
B. "Repeat the dose if your child vomits within 1 hour after taking medication." X
C. "Limit your child's potassium intake while she is taking this medication."
D. "Have your child drink a small glass of water after swallowing the medication."
Answer: D. "Have your child drink a small glass of water after swallowing the medication."
14. A nurse is providing teaching to a client who has a depressive disorder and a new prescription
for phenelzine. Which of the following foods should the nurse instruct the client to avoid?
A. Grapefruit
B. Spinach
C. Cottage cheese-cream cheese ok.
D. Smoked salmon
Answer: D. Smoked salmon

15. A nurse is planning care for a client who has COPD and weighs 99 lb. The provider has
prescribed a diet of 1.5 g protein/kg/day. How many grams of protein per day should the nurse
include in the client's dietary plan? (Round to the nearest whole number)
A. 68
B. 45
C. 55
D. 72
Answer: A. 68
16. A nurse is planning care for a client who has bipolar disorder and is experiencing mania.
Which of the following interventions should the nurse include in the plan?
A. Encourage the client to spend time in the day room
B. Withdraw the client's TV privileges if he does not attend group therapy X
C. Encourage the client to take frequent rest periods
D. Place the client in seclusion when he exhibits signs of anxiety X
Answer: C. Encourage the client to take frequent rest periods
17. A parish nurse is leading a support group for clients whose family members have committed
suicide. Which of the following strategies should the nurse plan to use during the group session?
A. Encourage clients to establish a timeline for their own grieving process
B. Initiate a discussion with clients about ways to cope with changes in family dynamics
C. Discourage clients from sharing negative aspects of their relationship with the deceased
persons
D. Assist clients in identifying ways suicide could have been prevented
Answer: B. Initiate a discussion with clients about ways to cope with changes in family
dynamics
18. A nurse manager observes two staff nurses reviewing the computer records of a client who is
not under their care. Which of the following actions should the nurse manager take first?
A. Instruct the nurses to close the client's computer record
B. Request the nurses present an in-service on client confidentiality

C. Advise the nurses to read the facility's confidentiality policy
D. Place documentation of the nurses' actions in the personnel file
Answer: A. Instruct the nurses to close the client's computer record
19. A nurse is reviewing the medical record of a client who has schizophrenia and is taking
clozapine. Which of the following findings should the nurse identify as a contraindication to the
administration of clozapine?
A. Heart rate 58/min
B. Fasting blood glucose 100 mg/dL
C. Hgb 14 g/dL
D. WBC count 2,900/mm3 - also agranulocytosis same thing or sore throat.
Answer: D. WBC count 2,900/mm3 - also agranulocytosis same thing or sore throat.
20. A nurse is caring for several clients on a medical-surgical unit. For which of the following
nurses activities is it required that the nurse use sterile gloves?
A. Inserting an NG tube
B. Administering total parenteral nutrition through a central venous access device
C. Initiating IV access
D. Performing tracheostomy care
Answer: D. Performing tracheostomy care
21. A nurse is caring for a client who is at 11 weeks of gestation. Which of the following
immunizations should the nurse give?
A. Influenza
B. Measles, mumps and rubella
C. Human papilloma virus
D. Varicella
Answer: A. Influenza
22. A nurse is inserting an indwelling catheter for a male client. Which of the following actions
should the nurse take?

A. Perform the cleansing procedure with a fresh swab two times
B. Lift the penis so that it is perpendicular to the client's body
C. Cleanse the tip of the penis in a side-to-side motion
D. Pick up the catheter 13 cm (5 cm) from its tip
Answer: B. Lift the penis so that it is perpendicular to the client's body
23. A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to
report to the provider. Which of the following findings should the nurse include in the teaching?
A. Bleeding gums-low platelet
B. Faintness upon rising
C. Swelling of the face
D. Urinary frequency
Answer: C. Swelling of the face
24. A nurse has received change-of-shift report for a group of clients. Which of the following
actions should the nurse take to manage time effectively?
A. Document client care at the end of the shift
B. Make the client to-do list for the day
C. Skip breaks until the client tasks are completed
D. Focus on several client tasks at a time
Answer: B. Make the client to-do list for the day
25. A nurse is developing a plan of care for a newborn whose mother tested positive for heroin
during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the
following actions should the nurse include in the plan?
A. Minimize noise in the newborn's environment
B. Administer naloxone to the newborn
C. Swaddle the newborn with his legs extended
D. Maintain eye contact with the newborn during feedings
Answer: A. Minimize noise in the newborn's environment

26. A nurse is assessing the fontanels of an 8-month-old infant. Which of the following findings
should the nurse recognize as an expected finding?
A. The anterior fontanel is open
B. The posterior fontanel is open
C. Both fontanels are the same size
D. Both fontanels show molding
Answer: A. The anterior fontanel is open
27. A nurse is caring for client who has acute diverticulitis. Which of the following diets should
the nurse recommend to the client? Diverticulosis-High fiber
A. High residue
B. Lactose-free
C. Gluten-free
D. Low-fiber
Answer: D. Low-fiber
28. A nurse is caring for a client who is 48 hr postoperative following a total hip arthroplasty.
Which of the following actions should the nurse include in the plan of care?
A. Administer low-dose heparin
B. Place the client on a full liquid diet
C. Use an incentive spirometer every 3 hr
D. Maintain the client on bed rest
Answer: A. Administer low-dose heparin
29. A nurse is providing teaching to the parent of an infant who has a cleft lip palate. Which of
the following feeding techniques should the nurse include in the teaching?
A. Burp the infant frequently during feedings
B. Position the nipple at the front of the infant's mouth
C. Hold the infant in a supine position
D. Use feeding devices without nipples
Answer: A. Burp the infant frequently during feedings

30. A nurse in an acute mental health care facility is prioritizing care for multiple clients. Which
of the following clients should the nurse see first?
A. A client who depressive disorder and requires assistance with ADLs
B. A client who has obsessive-compulsive disorder and is upset about a change in a daily routine
C. A client who is taking clozapine to treat schizophrenia and reports sore throat
D. A client who has narcissistic personally disorder and is mocking other during group therapy
Answer: C. A client who is taking clozapine to treat schizophrenia and reports sore throat
31. A nurse is planning care for a group of clients and is working with one licensed practical
nurse (LPN) and one assistive personnel (AP). Which of the following actions should the nurse
take first to manage her time effectively?
A. Develop an hourly time frame for tasks
B. Schedule daily activities
C. Determine goals of the day
D. Delegate tasks to the AP
Answer: C. Determine goals of the day
32. A nurse is performing an admission assessment for a client who is in the manic phase of
bipolar disorder. Which of the following behaviours should the nurse expect?
A. Performance of ritualistic behaviours
B. Suspiciousness and distrust-schizo
C. Distractibility and poor judgment
D. Reports of physical discomfort-anxiety
Answer: C. Distractibility and poor judgment
33. A nurse is caring for an infant who has coarctation of the aorta. Which of the following
should the nurse identify as an expected finding?
A. Weak femoral pulses?-they get upper extremity yper, lower extremity hypo
B. Frequent nosebleeds- yes
C. Upper extremity hypotension

D. Increased intracranial pressure
Answer: A. Weak femoral pulses?-they get upper extremity yper, lower extremity hypo
34. A nurse is developing an in-service about personality disorders. Which of the following
information should the nurse include when discussing borderline personality disorder?
A. "The client might act seductively"- histrionic
B. "The client is overly concerned about minor details"- ocd
C. "The client exhibits impulsive behavior"
D. "The client is exceptionally clingy to others"- dependent
Answer: C. "The client exhibits impulsive behavior"
35. A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon
assessment, the nurse notes tidaling in the water seal. Which of the following is an explanation
for the tidaling? TIDLING IN WATER SEAL AND CONTINUOUS IN SUCTION CHAMBER
OKAY! WATER SEAL BUBBLING IS AIR LEAK.
A. There is a loop of tubing below the drainage system
B. The system is working properly
C. The lung has re-expanded
D. The tubing is partially obstructed by clots
Answer: B. The system is working properly
36. A nurse in an emergency department is caring for a client who is experiencing stimulant
withdrawal. Which of the following findings should the nurse expect?
A. Runny nose
B. Decreased appetite-Increased appetite
C. Muscle spasms
D. Fatigue, agitated anxiety, increased appetite
Answer: D. Fatigue, agitated anxiety, increased appetite

37. A charge nurse is teaching new staff members about factors that increase a client's risk to
become violent. Which of the following risk factors should the nurse include as the best predictor
of future violence?
A. A history of being in prison
B. Experiencing delusions
C. Male gender
D. Previous violent behavior
Answer: D. Previous violent behavior
38. A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the
following actions should the nurse plan to take?
A. Instruct the client to lift her chin when swallowing X
B. Talk to the client during feeding X
C. Discourage the client from coughing during feedings
D. Sit at or below the client's eye level during feedings
Answer: D. Sit at or below the client's eye level during feedings
39. A nurse is providing teaching to a client who has a depressive disorder and a new prescription
for amitriptyline. Which of the following statements by the client indicates an understanding of
the teaching?
A. "I expect this medication to raise my blood pressure"
B. "I should take this medication on an empty stomach"
C. "I can continue to take St. John's wort while taking this medication"
D. "I know it will be a couple of weeks before the medication helps me feel better"
Answer: D. "I know it will be a couple of weeks before the medication helps me feel better"
40. A nurse is developing a nutritional care plan for a client who has COPD and severe dyspnea.
To promote intake, which of the following actions should the nurse include in the plan of care?
A. Ambulate the client before each meal
B. Offer the client three large meals each day X
C. Administer a bronchodilator after meals

D. Limit fluid intake with meals YES drinking before and after can bloat you
Answer: D. Limit fluid intake with meals YES drinking before and after can bloat you
41. A nurse in the emergency department is assessing a client who has major depressive disorder.
Which of the following actions should the nurse take first? (Exhibit)
A. Encourage the client to verbalize feelings *
B. Assess for hopelessness
C. Implement seizure precautions for the client
D. Administer ondansetron to the client for nausea
Answer: A. Encourage the client to verbalize feelings *
42. A home health nurse is completing screenings for elder abuse during client visits. Which of
the following findings should the nurse identify as an indication of potential elder abuse?
A. A client who lives with family members and begins to take more responsibility of self-care
B. A client who reports being given sedative medications by family members
C. A client who is taking warfarin and has several small bruises on her shins and hands
D. A client who schedules multiple visits with his provider every month
Answer: B. A client who reports being given sedative medications by family members
43. A nurse is planning care for a client who is to receive alteplase recombinant for a thrombus in
the coronary artery. Which of the following actions should the nurse include in the plan of care?
ALTEPLASE TREATS STROKES, HEART ATTACKS AND CLOTS.
A. Administer medications intramuscularly X- it is IV
B. Provide a diet low in protein X- why
C. Observe for bruising of the skin- check for bleeding
D. Monitor vital signs every hour for the first 4 hr- X every 15 min for the first hour
Answer: C. Observe for bruising of the skin- check for bleeding
44. A nurse is caring for a client who is postoperative following an appendectomy and is
receiving gentamicin. Which of the following assessment findings should the nurse identify as an
adverse effect of this medication?

A. Creatinine 2.3 mg/dL (0.6-1.2) nephrotoxicity
B. Respiratory rate 22/min
C. 2+ pitting edema of the ankles
D. Hgb 8.7 g/dL
Answer: A. Creatinine 2.3 mg/dL (0.6-1.2) nephrotoxicity
45. A nurse in an acute care facility is caring for a client who is homeless and has a decubitus
ulcer. Which of the following actions should the nurse take as a client advocate?
A. Gather dressing supplies for the client's discharge
B. Provide client teaching about nutrition
C. Consult with the facility's quality improvement team
D. Contact the facility's case management department?
Answer: D. Contact the facility's case management department?
46. A nurse is caring for client who has diarrhoea and is receiving intermittent enteral feedings.
Which of the following actions should the nurse take?
A. Discard the open can of formula after 36 hrB. Administer feedings at a slower rate---can give d10W.
C. Flush the tube with 10 mL of water after feedings
D. Provide chilled formula- room temperature
Answer: B. Administer feedings at a slower rate---can give d10W.
47. A nurse is caring for a client who is postoperative and has a new prescription for
hydromorphone. Which of the following actions should the nurse take?
A. Withhold the medication if the client does not appear to be in pain
B. Withhold the medication if the client has a fever
C. Document administration of the medication upon removal from the medication dispensing
system
D. Count the current number of unit doses available in the medication dispensing system
Answer: D. Count the current number of unit doses available in the medication dispensing
system

48. A nurse in a provider's office is caring for a client who asks about using acupuncture to
manage his osteoarthritis pain. The nurse should identify which of the following conditions as a
contraindication for receiving this treatment?
A. Herpes zoster
B. Hypertension
C. Obesity
D. Hypothyroidism
Answer: A. Herpes zoster
49. A nurse is assessing a client following abdominal surgery. Which of the following findings
should the nurse report to the provider?
A. Temperature 37.6 C (99.7 F)
B. Urinary output 20 mL/hr
C. Blood pressure 100/70 mm Hg
D. Serious drainage on abdominal dressing
Answer: B. Urinary output 20 mL/hr
50. A nurse in a long-term care facility is admitting a client who has dementia. Which of the
following actions should the nurse take to reduce the risk for client injury?
A. Place the bedside table at the foot of the bed
B. Keep the television on during the night
C. Assist the client to the toilet frequently
D. Raise the side rails up when the client is in bed
Answer: C. Assist the client to the toilet frequently
51. A certified IV nurse is providing education about peripherally inserted central catheters
(PICC) to a newly licensed nurse. Which of the following statements by the newly licensed nurse
indicates an understanding of the teaching?
A. "Use a vein in the middle of the lower arm to insert a PICC"- above elbow, below shoulder
B. "Flush a PICC using a 3-mililiter syringe"- 10 mL

C. "Informed consent is required prior to a PICC placement"
D. "Position the client's arm in adduction for PICC placement"
Answer: C. "Informed consent is required prior to a PICC placement"
52. A nurse is teaching self-administration of insulin glargine to a client who has type 1 diabetes
mellitus. Which of the following statements by the client indicates an understanding of the
teaching?
A. "I will take this insulin before meals"
B. "I will not mix this insulin with other types of insulin"
C. "I will rotate the injection sites between my arm and my thigh" (abdomen)
D. "I will shake the vial to mix the insulin" (you must roll)
Answer: B. "I will not mix this insulin with other types of insulin"
53. A nurse is caring for a client who is immunocompromised. Which of the following antiseptic
solutions should the nurse use to perform hand hygiene?
A. Isopropyl alcohol
B. Bleach
C. Chlorhexidine
D. Povidone-iodine
Answer: C. Chlorhexidine
54. A nurse is assessing a client in the emergency department. Which of the following actions
should the nurse take first? (exhibit)
A. Place the client on a cooling blanket
B. Obtain arterial blood gas levels
C. Elevate the head of the client's bed to 30
D. Administer an analgesic
Answer: B. Obtain arterial blood gas levels
55. A nurse is providing teaching to the parents of a newborn about newborn genetic screening.
Which of the following statements should the nurse include in the teaching?

A. "This test should be performed after your baby is 24 hours old"
B. "A nurse will draw blood from your baby's inner elbow"
C. "Your baby will be given 2 ounces of water to drink prior to the test"
D. "This test will be repeated when your baby is 2 months old"
Answer: A. "This test should be performed after your baby is 24 hours old"
56. A nurse is teaching a prenatal class about infection prevention at a community centre. Which
of the following statements by a client indicates an understanding of the teaching?
A. "I can visit my nephew who has chickenpox 5 days after the sores have crusted"
B. "I can clean my cat's litter box during my pregnancy"
C. "I should take antibiotics when I have a virus"
D. "I should wash my hands for 10 seconds with hot water after working in the garden"
Answer: A. "I can visit my nephew who has chickenpox 5 days after the sores have crusted"
57. A nurse is caring for a client who has end-stage kidney disease. The client's adult child asks
the nurse about becoming a living kidney donor for her father. Which of the following conditions
in the child's medical history should the nurse identify as a contraindication to the procedure?
A. Primary glaucoma
B. Amputation
C. Hypertension
D. Osteoarthritis
Answer: C. Hypertension
58. A home health nurse is planning care for a client who has Alzheimer's disease. Which of the
following actions should the nurse include in the plan of care?
A. Replace the carpet with hardwood floors
B. Place locks at the tops of exterior doors
C. Wear clothing with zippers instead of buttons?
D. Encourage physical activity prior to bedtime
Answer: B. Place locks at the tops of exterior doors

59. A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive
personal (AP) telling the client, "If you don't eat, I'll put restraints on your wrists and feed you."
The nurse should intervene and explain to the AP that this statement constitutes which of the
following torts?
A. Malpractice
B. Negligence
C. Assault
D. Battery
Answer: C. Assault
60. A nurse is reviewing a client's laboratory results prior to surgery. Which of the following
findings should the nurse report to the provider?
A. Bicarbonate 26 mEq/L--- 22-28 norm calcium 8-10
B. Chloride 100 mEq/L -- norm is 96-106
C. Potassium 3.8 mEq/L norm 3.5-5
D. Sodium 160 mEq/L - norm is 135-145
Answer: D. Sodium 160 mEq/L - norm is 135-145
61. A charge nurse is evaluating a newly licensed nurse's understanding of advance directives.
Which of the following statements by the newly licensed nurse indicates an understanding of
advance directives?
A. "I'll refer clients who do not have advance directives for legal assistance"
B. "I have to witness a client's signature on his advance directives"
C. "I have to document whether or not a client has prepared his advance directives"
D. "I'll encourage clients to follow their provider's wishes for end-of-life care"
Answer: C. "I have to document whether or not a client has prepared his advance directives"
62. A clinic nurse is assessing an 8-year-old child during an annual physical examination. Which
of the following findings indicates the need for intervention by the nurse?
A. The client eats at least one snack daily
B. The client's height has increased by 6.35 cm (2.5 in) 2 inches/year

C. The client's weight has increased by 0.9 kg (2 lb)- should gain at least 4-6 lbs (OR)
D. The client drinks 3 cups of 1% milk per day
Answer: C. The client's weight has increased by 0.9 kg (2 lb)- should gain at least 4-6 lbs (OR)
D. The client drinks 3 cups of 1% milk per day
63. A nurse is assessing a client who presents to the labor and delivery unit reporting the onset of
contractions. Which of the following findings should the nurse identify as a manifestation of
false labor?
A. Presence of a bloody show
B. Intermittent, painless contractions
C. Slow change in dilation and effacement
D. Contraction intensity increased by ambulation
Answer: B. Intermittent, painless contractions
64. A nurse is caring for a client who has a urinary tract infection and has been taking cefaclor.
Which of the following serum laboratory results indicates the medication is effective?
A. Creatinine 2.3 mg/dL
B. BUN 32 mg/dL
C. Eosinophils 3.9%
D. WBC 9,200 mm3
Answer: D. WBC 9,200 mm3
65. A charge nurse is mentoring a newly licensed nurse. Which of the following actions by the
newly licensed nurse indicates the need for intervention by the charge nurse?
A. Uses an IV infusion pump to administer total parenteral nutrition to a client
B. Inserts an NG tube for a client using clean technique
C. Crushes an SL tablet to administer into a client's feeding tube
D. Stabilizes a client's indwelling urinary catheter with the nondominated hand prior to inflation
of the balloon
Answer: C. Crushes an SL tablet to administer into a client's feeding tube

66. A nurse is reviewing laboratory results for a client who has a heart failure and notes a serum
potassium level of 5.2 mEq/L. Which of the following medications should the nurse withhold?
A. Furosemide
B. Spironolactone
C. Atorvastatin
D. Metoprolol
Answer: B. Spironolactone
67. A nurse is teaching a client who has migraine headaches how to use biofeedback to reduce
the need for pharmacological interventions. Which of the following information should the nurse
include in the teaching?
A. "Biofeedback stimulates certain pressure points to relax muscles"
B. "Biofeedback improves energy flow through soft tissue manipulation to increase circulation"
C. "Biofeedback requires concentration to control physiological responses"
D. "Biofeedback uses herbs to reduce inflammation"
Answer: C. "Biofeedback requires concentration to control physiological responses"
68. A nurse is teaching the parents of a child who has a new onset of seizures and is to undergo
an electroencephalogram (EEG) about the procedure. Which of the following instructions should
the nurse include in teaching?
A. "Give the child acetaminophen for pain following the procedure"
B. "Ensure the child's hair is clean and without conditioner before the procedure"
C. "Keep the child out of the sun for 4 hr following the procedure"
D. "Make the child NPO before the procedure"
Answer: B. "Ensure the child's hair is clean and without conditioner before the procedure"
69. A school nurse is teaching a parent about absence seizures. Which of the following
information should the nurse include?
A. "This type of seizure can be mistaken for daydreaming"
B. "This type of seizure lasts 30 to 60 seconds"
C. "The child usually has an aura prior to onset"

D. "This type of seizure has a gradual onset"
Answer: A. "This type of seizure can be mistaken for daydreaming"
70. A nurse in an outpatient mental health facility is providing teaching to a group of adolescents.
Which of the following statements by a client indicates an understanding of the teaching?
A. "I will limit my alcohol use to one drink daily while taking disulfiram" X not within 12 hours
B. "I will take my lithium on an empty stomach" X with food
C. "I will take the sustained-release methylphenidate every morning"
D. "I will avoid foods containing tyramine while taking fluoxetine" ssri X
Answer: C. "I will take the sustained-release methylphenidate every morning"
71. A nurse is caring for a client who is 4 days postpartum. Which of the following assessment
findings should the nurse expect? (Select all that apply)
A. Foul perineal odor
B. Lochia serosa
C. Postpartum... if blues, then correct (MAYBE)
D. Fundus displaced to the right
E. Fundus 4 cm (1.6 cm) below the umbilicus decends 1cm per day
Answer: B. Lochia serosa
C. Postpartum... if blues, then correct (MAYBE)
E. Fundus 4 cm (1.6 cm) below the umbilicus decends 1cm per day
72. A nurse is providing discharge teaching to a client following a total gastrectomy. The nurse
should instruct the client about which of the following medications
A. Vitamin K
B. Ranitidine
C. Metoclopramide
D. Vitamin B12- lifelong
Answer: D. Vitamin B12- lifelong

73. A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of
the following actions should the nurse take?
A. Hold hand flat to perform percussions on the child- cup shape
B. Perform the procedure twice a day (maybe)
C. Administer a bronchodilator after the procedure
D. Perform the procedure prior to meals * best time
Answer: D. Perform the procedure prior to meals * best time
74. A nurse at a community health clinic is planning care for an adolescent who recently learned
that she is pregnant and is concerned about her ability to afford and care for her baby. Which of
the following actions should the nurse take?
A. Contact the adolescent's parent for assistance
B. Advise the adolescent to place the newborn for adoption
C. Assist the adolescent in applying for Medicaid
D. Refer the adolescent to a local mental health clinic
Answer: C. Assist the adolescent in applying for Medicaid
75. A nurse is admitting an older adult client who is transferring from another facility. The nurse
notes pressure ulcers on the client's coccyx and abrasions around both wrists. Which of the
following actions should the nurse take to address suspicions of elder abuse?
A. Contact the family regarding the client's condition
B. Notify risk management
C. Privately interview the client about her condition
D. Inform the transferring agency of the client's condition
Answer: C. Privately interview the client about her condition
76. A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis
following a cerebrovascular accident. Which of the following actions by the nurse best promotes
communications among staff caring for the client?
A. Noting changes in the treatment plan in the client's medical record
B. Recording the client's progress in the nurses' notes

C. Posting swallowing precautions at the head of the client's bed
D. Having interdisciplinary team meetings for the client on a regular basis
Answer: D. Having interdisciplinary team meetings for the client on a regular basis
77. A nurse is caring for a client who has an indwelling urinary catheter. Which of the following
actions should the nurse take to provide catheter care?
A. Empty the collected urine once every 24 hr
B. Hang the drainage bag on a bed rail
C. Provide perineal hygiene after defecation
D. Change the indwelling catheter every 8 hr
Answer: C. Provide perineal hygiene after defecation
78. A nurse is assisting a client who has acute glomerulonephritis to choose menu items for
breakfast. Which of the following food choices should the nurse recommend?
A. Eggs- protein
B. Banana- proteinX
C. Smoked salmon- protein X
D. Bagel
Answer: D. Bagel
79. A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her
position at the clinic. Which of the following tasks should the nurse identify as tertiary
prevention?
A. Helping clients understand health screenings covered by their insurance plans
B. Using an electronic messaging system to remind clients when to take medications
C. Educating clients about contraindications to specific immunizations
D. Providing clients with information about the benefits of exercise
Answer: B. Using an electronic messaging system to remind clients when to take medications

80. A nurse in a long-term care facility is managing the care of an older adult client who has
difficulty swallowing and occasional choking during meals. The nurse should initiate a referral to
which of the following members of the interprofessional care team?
A. Occupational therapist
B. Respiratory therapist
C. Social worker
D. Speech-language pathologist
Answer: D. Speech-language pathologist
81. A nurse is performing a preoperative assessment for a client who reports having an allergy to
several goods. Which of the following food allergies indicates a risk factor for a latex allergy?
A. Peanuts
B. Eggs
C. Bananas
D. Shrimp
Answer: C. Bananas
82. A nurse is planning care for a client who is scheduled to receive a peripherally inserted
central catheter in the arm. Which of the following interventions is appropriate for the nurse to
include in the plan care?
A. Measure the arm circumference above the insertion site daily
B. Schedule an MRI post procedure to verify placement (Xray) X
C. Administer sedation for the procedure X - local anaesthetic
D. Use gauze to secure an arm board to involved extremity- used for midline
Answer: A. Measure the arm circumference above the insertion site daily
83. A nurse is caring for a group of clients. Which of the following wounds should the nurse
expect to heal by primary intention? PRIMARY FASTEST TYPE ON ITS OWN, SECONDARY
REQUIRES GRANULATION TISSUES AND CREATES SCAR TISSUES, AND TETRIARY
IS DELAYED WOUND CLOSURE.
A. Approximated surgical incision

B. Infected laceration- TERTIARY
C. Stage II pressure ulcer -SECONDARY
D. Partial-thickness burn- SECONDARY
Answer: A. Approximated surgical incision
84. A nurse is performing a change-of-shift assessment. Which of the following clients has the
priority finding?
A. A client who has a first-degree heart block and a heart rate of 62/min
B. A client who is 2 hr post cast placement and has a 2+ pitting edema and pallor
C. A client who has pneumonia with a productive cough and a fever of 38.8 C (101.8 F)
D. A client who has type 2 diabetes mellitus and a blood glucose of 250 mg/dL
Answer: B. A client who is 2 hr post cast placement and has a 2+ pitting edema and pallor
85. A nurse on a medical-surgical unit delegating tasks to an assistive personnel (AP). Which of
the following client care tasks is within the scope of practice for the AP?
A. Interpreting blood glucose values
B. Performing postmortem care
C. Explaining the steps for a 24-hr urine collection
D. Assisting with low-carbohydrate diet selections
Answer: B. Performing postmortem care
86. A nurse in a mental health clinic receives a request from a client who is undergoing
psychotherapy to obtain a copy of the therapist's notes. Which of the following responses should
the nurse make?
A. "We can provide a copy of your records, but the therapist's notes aren't included"
B. "I don't think you will benefit from reviewing your therapist's notes right now"
C. "Why are you interested in seeing your therapist's notes?"
D. "Are you not happy with your treatment?"
Answer: A. "We can provide a copy of your records, but the therapist's notes aren't included"

87. A nurse is providing teaching to a client who has thrombocytopenia following chemotherapy.
Which of the following statements indicates an understanding of the teaching?
A. "I will wipe my nose instead of blowing it"
B. "I will remove my shoes when I'm inside my house"
C. "I will floss between my teeth every time I brush"
D. "I will use an enema to manage my constipation"
Answer: A. "I will wipe my nose instead of blowing it"
88. A home care nurse is making follow-up visit with a client has COPD and is using a
compressed oxygen system in his home. Which of the following actions should the nurse take?
A. Store the oxygen tank wrench in a locked cabinet
B. Have the client store smaller tanks under his bed
C. Ensure that the client checks the gauge weekly
D. Place the oxygen tank away from curtains or drapes
Answer: D. Place the oxygen tank away from curtains or drapes
89. A nurse is conducting health promotion education regarding contraindications to combination
oral contraceptive use to a group of women. Which of the following conditions should the nurse
include in the teaching?
A. Renal calculi
B. Fibrocystic breast disease?
C. Fibromyalgia
D. Hypertension
Answer: D. Hypertension
90. A nurse is caring for a client following a thyroidectomy. For which of the following
complications should the nurse assess the client?
A. Hypokalaemia
B. Muscular depression
C. Laryngeal stridor
D. Hyperglycaemia

Answer: C. Laryngeal stridor
91. A nurse is teaching a client who is to start a new prescription for carbidopa-levodopa. Which
of the following instructions should the nurse include?
A. "Take with the protein snack" - limit protein
B. "Report dark-coloured urine"- this normal
C. "Monitor for hyperglycaemia"
D. "Change positions slowly"
Answer: D. "Change positions slowly"
92. A nurse is caring for a school-age child who is postoperative and received morphine via IV
bolus for pain 10 min ago. Which of the following findings is the nurse's priority?
A. Constipation
B. Sedation
C. Euphoria
D. Bradypnea
Answer: D. Bradypnea
93. A nurse is teaching the parents of a 6-year-old child who has sickle cell anaemia about
managing the disease. The nurse should emphasize the importance of which of the following
factors to prevent a sickle cell crisis?
A. Adequate hydration
B. Calorie restriction
C. Increased iron intake
D. A low-protein diet
Answer: A. Adequate hydration
94. A community health nurse is working with a group of clients. The nurse practices the ethical
principle of distributive justice by performing which of the following tasks?
A. Accepting the decision of an older adult client to live alone in her home
B. Ensuring that a client who is homeless receives preventive medical care- be fair

C. Keeping a promise to visit with a client who is housebound after the delivery of care
D. Being honest with the parents of a child about the need to report suspected abuse
Answer: B. Ensuring that a client who is homeless receives preventive medical care- be fair
95. A home health nurse is assessing a client who has amyotrophic lateral sclerosis (ALS) and
has had recent weight loss. Which of the following is the priority admission data for the nurse to
obtain?
A. Changes in appetite
B. Prescribed medications
C. Swallowing ability
D. Daily fluid intake
Answer: C. Swallowing ability
96. A nurse is caring for a client who has a new prescription for piperacillin/tazobactum 3.75 g
intermittent IV bolus Q6H to infuse over 30 min. Available is piperacillin/tazobactum 3.75 g in
50 mL 0.9% sodium chloride. The nurse should set the infusion pump to deliver how many
mL/hr?
Answer: 100
97. A nurse is assessing a client who has acute angle-closure glaucoma. Which of the following
findings should the nurse expect?
A. Increased light perception
B. Reddened cornea
C. Severe periocular pain
D. Gray cast sclera
Answer: C. Severe periocular pain
98. A nurse is caring for a client who has pneumonia and has gained 4.2 kg (9.3 lb) over the last
5 days. The client's laboratory values this morning are the following: WBC 10,000/mm 3, RBC
5.2 million/mm3, platelets 250,000mm3, BUN 32 mg/dL, and serum creatinine 2.1 mg/dL. The

nurse should report these findings to which of the following members of the interdisciplinary
team? And
A. Dietitian
B. Infection control nurse
C. Nephrologist
D. Cardiologist
Answer: C Nephrologist
99. A nurse is caring for a toddler who has retinoblastoma. Which of the following 100.findings
should the nurse expect?
A. Hyphema
B. Opacity of the lens
C. Nystagmus
D. White eye reflex
Answer: D. White eye reflex
100. A client who does not speak the same language as the nurse. The nurse is communicating
with the client using an interpreter. Which of the following actions should the nurse take?
A. Use gestures to convey meaning
B. Speak directly to the client
C. Pause in the middle of sentences
D. Speak slowly when talking to the interpreter
Answer: B. Speak directly to the client
101. A nurse is providing teaching about exercise to a client who is at 28 weeks of gestation.
Which of the following statements by the client indicates an understanding of the teaching?
A. "I can continue to do exercises that require the supine position" X
B. "I should check my pulse rate once every hour while exercising"
C. "I should increase my exercise level to prepare for labor" X
D. "I should drink 16 to 24 ounces of water after I exercise"
Answer: D. "I should drink 16 to 24 ounces of water after I exercise"

102. A nurse is providing discharge teaching to the parents of toddler who has cystic fibrosis.
What should nurse include?
A. "Use a nebulizer to administer a bronchodilator following airway clearance therapy"
B. "Restrict intake of foods that contain gluten"
C. "Perform chest percussion and postural drainage at least twice daily"
D. "Administer pancreatic enzymes on an empty stomach"- X with meal"
Answer: C. "Perform chest percussion and postural drainage at least twice daily"
103. A nurse is developing Plan of care for client who has preeclapsia and is to receive
magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse
include in the plan?
A. Monitor the FHR via Doppler every 30 min
B. Restrict the client's total fluid intake to 250 mL/hr
C. Give the client protamine if signs of magnesium sulfate toxicity occur
D. Measure the client's urine output every hour
Answer: D. Measure the client's urine output every hour
104. A nurse is planning discharge teaching for a client who is to start a new .prescription for
metoprolol. For which of the following should the nurse instruct the client to monitor and report
to the provider?
A. Tinnitus
B. Polyuria
C. Hyperglycemia
D. Bradycardia
Answer: D. Bradycardia
105. A nurse is providing teaching to the parents of a newborn who has been circumcised. Which
of the following instructions should the nurse include in the teaching?
A. "Remove yellow exudate around the penis"
B. "Wrap sterile gauze around the penis if bleeding occurs"

C. "Use soap to cleanse the site"
D. "Apply petroleum jelly to the glans with diaper changes"
Answer: D. "Apply petroleum jelly to the glans with diaper changes"
106. Care plan for bucks traction and is scheduled for surgery for a fractured femur of the right
leg. Which of the following interventions should the nurse delegate to an assistive personnel?
A. Remind the client to use the incentive spirometer
B. Ask the client to describe her pain
C. Observe the position of the suspended weight
D. Check the client's pedal pulse on the right leg
Answer: A. Remind the client to use the incentive spirometer
107. A nurse is assessing the growth and development of a 3-year-old child. Which of the
following questions should the nurse ask the parent to determine if the child exhibiting typical
developmental expectations?
A. "Can your child catch and throw a small ball?"
B. "Can your child ride a tricycle?"
C. "Can your child name give colors?"
D. "Can your child draw a stick figure?"
Answer: B. "Can your child ride a tricycle?"
108. A nurse is caring for a newborn whose mother was taking methadone during her .pregnancy.
Which of the following findings indicates the newborn is experiencing withdrawal?
A. Bradycardia
B. Acrocyanosis
C. Hypertonicity
D. Bulging fontanels
Answer: C. Hypertonicity
109. A charge nurse is admitting four clients to an acute care unit. Which of the following clients
should the nurse place near the nurses' station?

A. A client who is on fluid restriction
B. A client who is in Buck's traction
C. A client who has orthostatic hypotension
D. A client who has an open wound
Answer: C. A client who has orthostatic hypotension
110. A nurse is caring for a client who has pneumonia and tells the nurse, "I feel like an elephant
is sitting on my chest." The client is weak and unable to walk. After the nurse initiates chest pain
protocol, which of the following is the priority diagnostic test?
A. Serum potassium
B. 12-lead ECG
C. PT and INR
D. Chest x-ray
Answer: B. 12-lead ECG
111. A charge nurse on a medical- surgical unit is assisting with the emergency response plan
following an external disaster in the community. In anticipation of multiple client admissions,
which of the following current clients should the nurse recommend for early discharge?
A. A client who has COPD and a respiratory rate of 44/min
B. A client who has cancer with a sealed implant for radiation therapy
C. A client who is receiving heparin for deep-vein thrombosis
D. A client who is 1 day postoperative following a vertebroplasty
Answer: D. A client who is 1 day postoperative following a vertebroplasty
112. A home health nurse is caring for a child who has Lyme disease. Which of the following is
an appropriate action for the nurse to take?
A. Assess for skin necrosis
B. Educate the family to avoid sharing personal belongings
C. Ensure the state health department has been notified
D. Administer antitoxin
Answer: C. Ensure the state health department has been notified

113. A nurse is reviewing annual educational requirements for fire safety. Identify the sequence
the nurse should use when operating a fire estinguisher.
A. Point the hose at the base of the fire
B. Sweep the extinguisher from side to side
C. Squeeze the handles together
D. Unlock the handle by pulling on the pin
Answer: D. Unlock the handle by pulling on the pin
A. Point the hose at the base of the fire
B. Sweep the extinguisher from side to side
C. Squeeze the handles together
114. A nurse is caring for a client who has a nasogastric tube. Which of the following actions
should the nurse take to verify placement prior to each feeding.
A. Auscultate air insertion into the tube
B. Test the bilirubin level of gastric contents
C. Palpate the abdomen for tube placement
D. Test the pH of gastric contents
Answer: D. Test the pH of gastric contents
115. A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks gestation.
Which of the following actions should the nurse take?
A. performan leopold maneuvers prior to auscultating the fetal heart rate
B. position the ultrasound stethoscope above the symphysis pubis to assess fetal heart rate
C. measure the fundal height to determine the placement of the ultrasound stethoscope
D. place the client in a side lying position prior to assessing the fetal heart rate
Answer: B. position the ultrasound stethoscope above the symphysis pubis to assess fetal heart
rate
116. While performing a routine assessment, a nurse notices fraying on the electrical cord of a
client CPM device. Which of the following actions should the nurse take first.

A. ensure the device inspection sticker is current
B. report the defect to the equipment maintenance staff
C. remove the device from the room
D. initiate a requisition for a replacement CPM device
Answer: C. remove the device from the room
117. A nurse is caring for a newly admitted client who has bacterial meningitis. Which following
actions should the nurse take?
A. Implement seizure precautions
B. Monitor the client for hypoglycaemia
C. Perform range-of-motion exercises once per shift
D. Place the client in high-Fowler's position
Answer: A. Implement seizure precautions
118. A nurse is providing teaching to a client about the adverse effects sertraline. Which of the
following adverse effects should the nurse include?
A. Excessive sweating
B. Increased urinary frequency
C. Dry cough
D. Metallic taste in mouth
Answer: A. Excessive sweating
119. A nurse is assessing a client who is in active labor. Which of the following findings should
the nurse report to the provider?
A. Contractions lasting 80 seconds- too long?
B. Depending on frequency*
C. FHR baseline 170/min normal 110-160 maybe this! * Early decelerations in the FHR
D. Temperature 37.4 C (99.3 F)
Answer: C. FHR baseline 170/min normal 110-160 maybe this! * Early decelerations in the
FHR

120. A nurse is preparing a client to undergo cardiac cauterization. Which of the following tasks
should the nurse perform prior to the procedure?
A. Draw blood specimens for culture and sensitivity
B. Administer nitro-glycerine 0.4 mg SL 30 min before the procedure
C. Transport the client to radiology for a CT scan
D. Obtain a CBC with differential?
Answer: D. Obtain a CBC with differential?
121. A nurse is developing a plan of care for a client who has schizophrenia and is experiencing
auditory hallucinations. Which of the followings actions should the nurse include in the plan?
A. Ask the client directly what he is hearing
B. Encourage the client to lie down in a quiet room
C. Avoid eye contact with the client
D. Refer to the hallucinations as if they are real
Answer: A. Ask the client directly what he is hearing
122. A nurse is reviewing the preadmission laboratory test results of a client who is to undergo
hip arthroplasty in 2 days. Which of the following results should the nurse report to the provider?
A. Sodium 142
B. Potassium 3.3
C. Blood Glucose 80 mg/dl
D. pt 11.5 seconds
Answer: B. Potassium 3.3
123. A nurse is in the emergency department is caring for client who has a new diagnosis of acute
myocardial infarction and is being treated with a thrombolytic, aspirin, and IV heparin. Which of
the following findings should indicate to the nurse that the client is experiencing a satisfactory
response to these interventions?
A. The client's stool is guaiac positive
B. S3 heart sounds are present
C. The client's aPPT is two times the control

D. Q wave is noted on the cardiac monitor tracing
Answer: C. The client's aPPT is two times the control
124. A nurse observes a client on the psychiatric unit muttering and standing near a window. The
client states, "The voices are telling me to jump." Which of the following is an appropriate
response by the nurse?
A. "I understand the voices are frightening you, but I do not hear any voices"
B. "Do you recognize the voices as belonging to anyone you know?"
C. "You shouldn't be afraid when you think the voices are telling you to hurt yourself"
D. "That can't be true. The only voices in this room are yours and mine"
Answer: A. "I understand the voices are frightening you, but I do not hear any voices"
125. A home health nurse is visiting a client whose partner states that she is overwhelmed by
caring for him. When suggesting respite care, which of the following explanation should the
nurse provide?
A. "Respite care includes volunteers who will perform household tasks"
B. "Respite care provides clinicians to work with you in caring for your husband"
C. "Respite care offers financial resources to help care for your husband"
D. "Respite care allows for time away from caring for your husband"
Answer: D. "Respite care allows for time away from caring for your husband"
126. A nurse working in the postpartum unit is reviewing a client's new prescription for
methylergonovine. The nurse should recognize that which of the world following is a
contraindication for this medication?
A. hypertension
B. confusion
C. chlamydia
D. polyuria
Answer: A. hypertension

127. A nurse is caring for a client who is in labor and has received an epidural. Which following
actions should the nurse take?
A. Decrease the maintenance infusion rate of IV fluid X more hypotension
B. Have protamine sulphate available at the bedside- X Heparin
C. Reposition the client side-to-side each hour
D. Monitor the client hypertension X hypotension
Answer: C. Reposition the client side-to-side each hour
128. A charge nurse observes a coworker who has impaired coordination and is drowsy while
performing routine tasks. Which of the following actions should the nurse take first?
A. document the observations about the nurse's behavior
B. report the nurses' behavior to the nurse manager
C. reassign the nurse's client-care duties to another nurse
D. obtain support from another nurse before filing report
Answer: B. report the nurses' behavior to the nurse manager
129. A nurse is receiving change-of-shift report for a group of clients. Which of the following
clients should the nurse plan to assess first?
A. A client who has sinus arrhythmia and is receiving cardiac monitoring
B. A client who has epidural analgesia and weakness in the lower extremities
C. A client who has a hip fracture and a new onset of tachypnoea
D. A client who has diabetes mellitus and haemoglobin A1C of 6.8%
Answer: C. A client who has a hip fracture and a new onset of tachypnoea
130. A nursed is caring for a client who has implanted venous access port. Which of the
following should the nurse use to access the port?
A. A noncaring needle- Huber point needle
B. A butterfly needle
C. An Angio catheter
D. A 25-gauge needle
Answer: A. A noncoring needle- Huber point needle

131. A nurse is receiving change-of- shift report for four clients. Which of the following clients
should the nurse assess first?
A. A client who has leukaemia and a platelet level of 95,000/mm3 (150-400)
B. A client who has hepatitis B and total bilirubin of 1.2 mg/dL (0.1-1.0)
C. A client who has diabetes mellitus and a HbA1c of 5.2%
D. A client who received IV furosemide and has a serum potassium of 3.6 mEq/L
Answer: A. A client who has leukaemia and a platelet level of 95,000/mm3 (150-400)
132. A nurse is admitting a client who has a history of atrial fibrillation. The nurse should
recognize the atrial fibrillation places the client at risk for which conditions?
A. cardiac tamponade
B. pulmonary emboli
C. hemothorax
D. widened pulse pressure
Answer: B. pulmonary emboli
133. A nurse is teaching about home care to the parents of an infant who has a tracheostomy.
Which of the following instruction should the nurse include in the teaching?
A. set the suction machine to 60 mm Hg
B. advance the suction catheter just past the point of resistance
C. instill 2 ml of saline in the tracheostomy prior suctioning
D. apply suction for 30 seconds after advancing the catheter
Answer: A. set the suction machine to 60 mm Hg
134. A nurse is caring for a client who has given informed consent for electroconvulsive therapy.
Just before the procedure, the client tells the nurse she is considering not going forward with the
treatment. Which of the following statements by the nurse is appropriate?
A. "You don't have to go through with the treatment"
B. "It's okay to be nervous before this treatment"
C. "Most people who have this procedure feel better following the treatment"

D. "Your doctor wouldn't have ordered this treatment unless it was necessary"
Answer: A. "You don't have to go through with the treatment"
135. A home health nurse is providing teaching about home safety to an older adult client. Which
of the following statements by the client indications that the teaching has been effective?
A. I put on socks when getting out of bed at night
B. I have marked the steps with black tape
C. I have grab bars next to my tub
D. I have played throw rugs in the hallways
Answer: C. I have grab bars next to my tub
136. A nurse is providing teaching to a client who is undergoing radiation therapy and has
stomatitis. Which of the following responses by the client indicate understanding of the
teaching?
A. I should gargle with an alcohol-based mouthwash
B. I should use a soft-bristle toothbrush to clean my teeth after meals
C. I should limit my intake of dairy products to prevent nausea
D. I should moisten my lips with lemon-glycerine swabs
Answer: B. I should use a soft-bristle toothbrush to clean my teeth after meals
137. A nurse is preparing to administer the first dose of cefazolin via intermittent IV infusion to a
client. Which of the following actions should the nurse take first?
A. Check the compatibility of cefazolin with the client's existing IV fluids
B. Obtain the reconstituted antibiotic from pharmacy
C. Review the client's allergy history
D. Assess the IV for patency
Answer: C. Review the client's allergy history
138. A nurse is caring for a child who reports migraine headaches for the past 4 months. Which
of the following actions should the nurse take first?
A. review the child's electronic pain diary

B. set up an appointment with the school
C. Refer the family to a chronic pain support group
D. Request a change in medication from the provider
Answer: A. review the child's electronic pain diary
139. A nurse is providing teaching to a client who is receiving misoprostol for induction of labor.
Which of the following information should the nurse include in the teaching?
A. You will have intermittent fetal monitoring while you receive the medication" (intermittent??)
B. "You will lie on your side for 30 minutes after the medication is inserted" (yes lie down for 30
minutes but only when aborting)
C. "You will have a urinary catheter inserted prior to the placement of the medication" ( d. you
should empty your bladder prior to insertion)- placement is for abortion, you get a cath when you
are under epidural
D. You will have oxytocin initiated within 3 hors of administration of the medication
Answer: B. "You will lie on your side for 30 minutes after the medication is inserted" (yes lie
down for 30 minutes but only when aborting)
D. You will have oxytocin initiated within 3 hours of administration of the medication
140. A nurse is assessing the peripheral catheter insertion site of a client who is receiving an
infusion. The nurse notices redness and warmth to touch around the insertion site. The nurse
should document the finding as which of the following complications?
A. Phlebitis
B. Extravasation
C. Circulatory overload
D. Infiltration
Answer: A. Phlebitis
141. A nurse is caring for a client who is in active labor and notes the FHR baseline has been
100/min for the past 15 min. The nurse should identify which of the following conditions as a
possible cause for fetal bradycardia.
A. maternal fever

B. fetal anemia
C. maternal hypotension
D. chorioamnioitis
Answer: C. maternal hypotension
142. A nurse is preparing to administer an IV medication to a client and accidentally punctures
the IV bag causing the medication to leak on the counter. Which of the following medications
requires the nurse to follow facility procedures in the safe handling of a biohazards material
spill?
A. Doxorubicin hydrochloride- chemo drug it is hazardous
B. Ampicillin sodium
C. Metronidazole
D. Phenytoin
Answer: A. Doxorubicin hydrochloride- chemo drug it is hazardous
143. A nurse is reviewing the medication administration record of a client who has rheumatoid
arthritis and is 1 day postoperative following a left total hip arthroplasty. Which of the following
medication places the client at risk for delayed wound healing?
A. Omeprazole 0
B. Morphine
C. Prednisone (steroid)
D. Digoxin
Answer: C. Prednisone (steroid)
144. A nurse is an emergency department is reviewing the medical record for a client who is
having an acute myocardial infarction. Which of the following findings places the client at risk if
he receives alteplase?
A. hip arthroplasty 1 week ago
B. family history of malignant hypertension
C. Chronic obstructive pulmonary disease
D. Acute renal failure 6 months

Answer: A. hip arthroplasty 1 week ago
145. A nurse is caring for a client who has permanent dropping on the left side off the face
following a cerebrovascular accident (CVA). The client refuses to see any family members.
Which of the following interventions will be assist the client to adapt to his body image change?
A. Establish short-term goals that will enable the client to look in the mirror (OR)
B. Offer contact information for CVA recovery support groups
C. Initiate a family conference to address the issue
D. Educate the client about short- and long-term effects of a CVA
Answer: D. Educate the client about short- and long-term effects of a CVA
146. A nurse is teaching the parent of an infant who who's positional plagiocephaly. Which of the
following statements by the parent indicates an understanding of the teaching?
A. "I should avoid tummy time when my baby is wearing the helmet"
B. "I should place my baby in the left side-lying position at night when using the helmet"
C. "I should keep the helmet on my baby for 23 hours a day" (18-22 hours a day)
D. "I should expect to have my baby wear this helmet for 10 months"
Answer: C. "I should keep the helmet on my baby for 23 hours a day" (18-22 hours a day)
147. A nursed manager is updating protocols for the use of belt restraints. Which of the following
guidelines should the nurse include?
A. Remove the client's restraints every 4 hr- its every 2 hours
B. Document the client's condition every 15 min
C. Attach the restraint to the bed's side rails
D. Request a PRN restraint prescription for clients who are aggressive X
Answer: B. Document the client's condition every 15 min
148. A nurse is assessing a client who has fine hair, exophthalmos, ad reports intolerance to heat.
Which of the following endocrine disorders is associated with these findings?
A. Hyperparathyroidism
B. Hyperthyroidism

C. Hypoparathyroidism
D. Hypothyroidism
Answer: B. Hyperthyroidism
149. A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing.
Which of the following examples should the nursed include in the teaching?
A. Leaving a nasogastric tube clamped after administering oral medication
B. Documenting communication with a provider in the progress notes of the client's medical
record
C. Administering potassium via IV bolus
D. Placing a yellow bracelet on a client who is at risk for falls
Answer: C. Administering potassium via IV bolus
150. A nurse is an acute care facility is caring for four clients. Which of the following clients
should the nurse refer for speech therapy?
A. A client who has dysphagia following a stroke
B. A client who has sensorineural hearing loss
C. An older adult client who has stage III Alzheimer's disease
D. A client who is postoperative following a tonsillectomy and adenoidectomy
Answer: A. A client who has dysphagia following a stroke