ATI COMPREHENSIVE PRACTISE QUIZ
1. A nurse is assessing a client who received 2 units of packed RBCs 48 hours ago. Which of the
following findings should indicate to the nurse that the therapy has been effective?
Answer: Haemoglobin 14.9 g/dl
Rationale:
The nurse should identify that packed RBCs are administered to clients who have a decreased
level of haemoglobin or hematocrit. This haemoglobin level is within the expected reference
range of 14 to 18 g/dl for males and 12 to 16 g/dl for females, indicating the therapy has been
effective.
2. A nurse working in a n emergency department is triaging four clients. Which of the following
clients should the nurse recommend for treatment first?
Answer: A middle adult client who has unstable vital signs.
Rationale:
Using the stable versus unstable approach to client care, the nurse should recommend priority
treatment for the client who has unstable vital signs because this client requires immediate
treatment to reduce the risk of further injury or possible death.
3. A nurse is caring for a client who has fluid volume overload. Which of the following tasks
should the nurse delegate to the CNA?
Answer: Measure the client’s daily weight
Rationale:
It is within the CNAs range of function to measure a client’s daily weight, so the nurse should
delegate this task to them.
4. A nurse is preparing to administer mannitol 0.2g/kg IV bolus over 5 min as a test dose to a
client who has severe oliguria. The client weighs 198lb. What is the amount in grams the nurse
should administer?
Answer: 18 g
Rationale:
Convert the client's weight from pounds to kilograms to determine the correct dosage. Then,
multiply the weight in kilograms by the prescribed dose to calculate the amount of medication to
administer.
5. A nurse is conducting a physical examination for an adolescent and is assessing the range of
motion of the legs. Which of the following images indicates the adolescent is abducting the hip
joint?
Answer: In the correct image, the adolescent is abduction the hip joint by moving the leg away
from the midline of the body.
Rationale:
Abduction of the hip joint involves moving the leg laterally away from the midline of the body.
This movement increases the angle between the legs and demonstrates the range of motion of the
hip joint in the abduction direction.
6. A nurse is caring for a client who has hyperthyroidism. Which of the following findings should
the nurse expect?
Answer: Tremors
Rationale:
Tremors are a manifestation of hyperthyroidism, along with tachycardia, diaphoresis, weight
loss, insomnia, and exophthalmia.
7. A nurse is assessing a school-aged child who has bacterial meningitis. Which of the following
findings should the nurse expect?
Answer: Nuchal rigidity
Rationale:
This is a manifestation of bacterial meningitis.
8. A nurse is assessing a newborn’s heart rate. Which of the following actions should the nurse
take?
Answer: Auscultate the apical pulse at least 1 min.
Rationale:
The nurse should auscultate the apical pulse to obtain an accurate assessment of heart rate and
rhythm. Auscultation of a newborn’s heart sounds can be difficult because of the rapid rate and
the transmission of respiratory sounds.
9. A nurse is preparing to assist with a thoracentesis for a client who has pleurisy. The nurse
should plan to perform which of the following actions?
Answer: Instruct the client to avoid coughing during the procedure.
Rationale:
It is important for the nurse to remind the client to avoid coughing and to lie still during a
thoracentesis to avoid puncturing the pleura.
10. A nurse in the ED is assessing a preschooler who has a facial laceration. The nurse should
identify which of the following findings as a potential indication of child sexual abuse?
Answer: The child exhibits discomfort while walking.
Rationale:
The nurse should identify this finding as a potential indication of child sexual abuse.
11. A nurse is preparing to teach about dietary management to a client who has Crohn’s disease
and an entero enteric fistula. Which of the following nutrients should the nurse instruct the client
to decrease in their diet?
Answer: Fiber
Rationale:
The nurse should instruct the client to consume a low-fiber diet to reduce diarrhea and
inflammation.
12. A nurse is caring for a client who has a prescription for a continuous passive motion (CPM)
machine following a total knee arthroplasty. Which of the following actions should the nurse
take?
Answer: Turn off the CPM machine during mealtime.
Rationale:
This promotes client comfort and dietary intake.
13. A nurse is preparing to initiate IV access for an older adult client. Which of the following
sites should the nurse select when initiating the IV for the client?
Answer: Radial vein of the inner arm.
Rationale:
This site will have adequate subcutaneous tissue
14. A nurse is developing a client education program a bout osteoporosis for older adult clients.
The nurse should include which of the following variables as a risk factor for osteoporosis?
Answer: Sedentary lifestyle.
Rationale:
This is a risk factor for osteoporosis. The nurse should encourage older adult clients to engage in
weight-bearing exercises because they will promote bone health by increasing calcium and
phosphorus levels.
15. A nurse in an ED is caring for a child who has a fever and fluid-filled vesicles on the trunk
and extremities. Which of the following interventions should the nurse identify as the priority?
Answer: Initiate transmission-based precautions
Rationale:
When using the urgent versus nonurgent approach to client care, the nurse should determine that
the priority action is to initiate transmission-based precautions for the child. The child most
likely has varicella. Therefore, the nurse should isolate the child to prevent the spread of the
infection.
16. A nurse is caring for a client who has a clogged percutaneous gastrostomy feeding tube.
Which of the following actions should the nurse take first?
Answer: Change the position of the client.
Rationale:
When providing client care, the nurse should use the least restrictive intervention first. Therefore,
the nurse should reposition the client to remove any kinks in the tube, which can lead to
clogging. If this method is unsuccessful, the nurse should attempt to flush or aspirate the client’s
tube to remove the clog.
17. A home health care nurse is developing a teaching plan for a client who has a new ileostomy.
Which of the following instructions should the nurse include?
Answer: Empty the appliance when it is one-third to one-half full.
Rationale:
The ileostomy pouch should be emptied when it is one-third to one-half full to prevent stool
leakage and skin irritation.
18. A nurse is reviewing the laboratory report of a client who has end-stage kidney disease and
received hemodialysis 24 yr ago. Which of the following lab values should the nurse report to the
provider?
Answer: Sodium 148 mEq/L
Rationale:
The nurse should report this sodium level because it is above the expected reference range of 136
to 145 mEq/L, indicating hypernatremia. Clients who have kidney disease often retain sodium
and require sodium-restricted diets.
19. A nurse is caring for four clients. Which of the following tasks should the nurse delegate to a
CNA?
Answer: Arrange the lunch tray for a client who has a hip fracture.
Rationale:
Assisting a client with meals is within the range of function of the CNA.
20. A nurse is preparing a client for a paracentesis. Which of the following actions should the
nurse take?
Answer: Instruct the client to void.
Rationale:
The nurse should instruct the client to void prior to the procedure because an empty bladder
decreases the risk of a bladder puncture and minimizes the client’s discomfort during the
procedure.
21. A nurse has received change of shift report on four assigned clients. For which of the
following clients should the nurse intervene to prevent a potential food and medication
interaction?
Answer: A client who is receiving an MAOI and is requesting a cheeseburger for dinner.
Rationale:
This client’s food selection contains tyramine. Clients prescribed an MAOI must restrict the
intake of foods that contain tyramine due to adverse effects, such as hypertension.
22. A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe
pain in multiple joints. Which of the following actions should the nurse plan to take?
Answer: Allow for frequent rest periods throughout the day.
Rationale:
The nurse should encourage the client to balance rest with exercise to maintain muscle strength,
joint function, and range of motion.
23. A nurse is caring for a client who is receiving continuous bladder irrigation following a
transurethral resection of the prostate. The client reports bladder spasms, and the nurse observes
a decreased urinary output. Which of the following action should the nurse take?
Answer: Irrigate the catheter with 0.9% sodium chloride irrigation.
Rationale:
Decreased urine output and bladder spasms indicate internal obstruction of the catheter.
Therefore, the nurse should irrigate the catheter with 0.9% sodium chloride irrigation and notify
the provider if the obstruction does not clear.
24. A nurse is assessing a client who has COPD. Which of the following findings should the
nurse expect?
Answer: pH 7.31
Rationale:
Respiratory acidosis is an expected finding for a client who has COPD. The expected reference
range of pH is 7.35-7.45. A pH level of less than 7.35 indicates acidosis. For a client who has
COPD, a decrease in pH will be accompanied by an increase in the level of carbon dioxide over
the expected reference range of 35 to 45 mm Hg, indicating respiratory acidosis.
25. A nurse in a community centre is providing an educational session to a group of clients about
ovarian cancer. Which of the following manifestations of ovarian cancer should the nurse include
in the teaching?
Answer: Abdominal bloating
Rationale:
The nurse should include the presence of abdominal bloating as an early manifestation of ovarian
cancer. Other manifestations include an increase in abdominal girth, pelvic or abdominal pain,
early satiety, and urinary frequency or urgency.
26. A nurse is caring for a client who has active TB. Which of the following actions should the
nurse plan to take to prevent the transmission of the disease?
Answer: Have the client wear a surgical mask while being transported outside the room. This
will prevent the transmission of the disease.
Rationale:
Tuberculosis (TB) is an airborne disease, and wearing a surgical mask prevents the release of
infectious respiratory droplets during transport. This minimizes the risk of disease transmission
to others.
27. A nurse is caring for a group of clients. Which of the following clients should the nurse
attend to first?
Answer: An older adult client who is anxious and attempting to pull out an IV line. This client is
at greater risk of injury.
Rationale:
The older adult client who is anxious and attempting to pull out an IV line is at risk for injury,
such as bleeding or infection, and requires immediate attention to prevent harm. Addressing this
behavior ensures patient safety and prevents complications.
28. An RN is observing an LPN and a CNA move a client up in bed. For which of the following
situations should the nurse intervene?
Answer: The LPN and the CNA grasp the client under his arms to lift him up in bed.
Rationale:
They should not grasp the client under the arms when lifting, as this can result in shoulder
dislocation or other injuries to the client. The RN should intervene and instruct the nurses to use
a draw sheet or friction-reducing device to lift the client.
29. A nurse is preparing to administer insulin to a client via a pen device. Which of the following
actions should the nurse take?
Answer: Hold the insulin pen device perpendicular to the client’s skin to inject the medication.
Rationale:
This ensures the insulin enters the subcutaneous tissue.
30. A nurse is caring for a client who has immunosuppression and a continuous IV infusion.
Which of the following actions should the nurse take?
Answer: Monitor the client’s mouth every 8 hr.
Rationale:
Check for manifestations of infection, such as sores or lesions.
31. A nurse is providing teaching about advance directives to a middle-aged adult client. Which
of the following client responses indicates an understanding of the teaching?
Answer: “I can designate my partner as my health care surrogate.”
Rationale:
This statement indicates that the client recognizes that designating a health care surrogate is part
of advance directives.
32. A nurse is assessing a client following a vaginal delivery and notes heavy lochia and a boggy
fundus. Which of the following medications should the nurse expect to administer?
Answer: Oxytocin
Rationale:
This is a hormone that stimulates uterine contractions, to decrease vaginal bleeding.
33. A nurse manager is planning to use a democratic leadership style with the nurses on the unit.
Which of the following actions by the nurse manager demonstrates a democratic leadership
style?
Answer: Seeks input from the other nurses.
Rationale:
This includes members of the team when making decisions and encourages staff members to
participate in the decision-making process.
34. A nurse is assigning task roles for a group of clients in a community mental health clinic.
Which of the following tasks should the nurse assign to the member of the group functioning as
the orienteer?
Answer: Noting the progress of the group toward assigned goals. This is the task of the
orienteer.
Rationale:
The orienteer in a group setting helps keep the group focused on its goals and ensures that
progress is being made toward them. This role involves guiding the group back to its objectives
and noting any progress or deviations.
35. A nurse is creating a plan of care for a newly admitted child. Which of the following actions
should the nurse include in the plan? See Exhibit button Administer high-dose antibiotic therapy.
Answer: Administer high-dose antibiotic therapy.
Rationale:
Children who have cystic fibrosis metabolize antibiotics more rapidly and require higher doses
of antibiotics to help fight aggressive infections such as Burkholderia cepacia.
36. A nurse is caring for a newborn immediately after delivery. Which of the following
interventions should the nurse implement to prevent heat loss by conduction?
Answer: Use a protective cover on the scale when weighing the infant.
Rationale:
Heat loss by conduction is a loss of heat between the newborn’s skin and the cooler surface
beneath it.
37. A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following
actions is the nurse’s priority?
Answer: Assist with deep breathing and coughing.
Rationale:
The priority action the nurse should take when using the airway, breathing, circulation approach
to client care is to assist the client with deep breathing and coughing, which reduces the risk of
postop pneumonia.
38. A nurse in an outpatient mental health clinic is caring for four clients. The nurse should
recognize that which of the following clients is effectively using sublimation as a defense
mechanism?
Answer: A client who channels their energy into a new hobby following the loss of their job.
Rationale:
Channeling negative feelings over the loss of their job into a new hobby is using the defense
mechanism of sublimation.
39 .A nurse is assessing f or correct placement of a client’s NG feeding tube prior to
administering a bolus feeding. Which of the following actions should the nurse take?
Answer: Aspirate contents from the tube and verify the pH level.
Rationale:
The nurse should verify that the pH level of the client’s gastric aspirate is less than 5 to
determine proper placement.
40 .An antepartum nurse is caring for four clients. For which of the following clients should the
nurse initiate seizure precautions?
Answer: A client who is at 33 weeks gestation and has severe gestational hypertension.
Rationale:
The nurse should initiate seizure precautions for a client who has severe gestational because
extremely elevated blood pressure in an antepartum client can trigger seizure activity. The nurse
should provide the client with a quiet, darkened environment, place suction equipment and
oxygen at the bedside, and position the call light within the client’s reach.
41. A nurse is providing discharge teaching to a client who is to receive home oxygen therapy.
Which of the following instructions should the nurse include in the teaching?
Answer: Wear clothing made with cotton fabrics while oxygen is in use.
Rationale:
Woolen and synthetic fabrics can generate static electricity, which increases the risk of a fire.
42. A nurse is providing teaching for a client who has a fracture of the right fibula with a shortleg cast in place and a new prescription for crutches. The client is non-weight bearing for 6
weeks. Which of the following instructions should the nurse include in the teaching?
Answer: Use the three-point gait.
Rationale:
This allows the client to be mobile without bearing weight on the affected extremity.
43. A nurse is preparing to transfer a client from the ICU to the medical floor. The client was
recently weaned from mechanical ventilation following a pneumonectomy. Which of the
following information should the nurse include in the change-of-shift report?
Answer: The time of the client’s last dose of pain medication.
Rationale:
The nurse should recognize than an effective handoff report provides a baseline of the client’s
status for comparison and should include any recent changes or priority situations affecting the
client’s condition. The time of the client’s last dose of pain meds is important to include so the
receiving nurse can anticipate what time to give the next dose.
44. A nurse is assessing a n infant who has hydrocephalus and is 6 hr postop following placement
of a ventriculoperitoneal (VP) shunt. Which of the following findings should the nurse report to
the provider?
Answer: Irritability when being held.
Rationale:
This is a manifestation of increased intracranial pressure, which is an indication that the VP shunt
is malfunctioning. This finding should be reported to the provider immediately.
45. A nurse is caring for a client who has a prescription for chlorpromazine. Which of the
following finding should the nurse identify as an indication that the medication is effective?
Answer: Decreased hallucinations.
Rationale:
This is an antipsychotic medication administered to decrease hallucinations and other
manifestations of schizophrenia.
46. A nurse is providing teaching about lithium to a client who has bipolar disorder. Which of the
following statements should the nurse include in the teaching? “Notify your provider if you
experience increased thirst”
Answer: Increased thirst is a manifestation of lithium toxicity.
Rationale:
The nurse should instruct the client to report increased thirst, vomiting, diarrhea, or tremors to
the provider.
47. A nurse caring for a client who has a fecal impaction. Which of the following actions should
the nurse take when digitally evacuating the stool?
Answer: Insert a lubricated gloved finger and advance along the rectal wall. This is the correct
way of doing this.
Rationale:
When digitally evacuating a fecal impaction, the nurse should use a lubricated gloved finger to
gently advance along the rectal wall to avoid injury to the rectal mucosa. This technique ensures
the stool is removed safely without causing harm to the client.
48. A nurse is planning to delegate client care tasks to a CNA. Which of the following tasks
should the nurse plan to delegate to the CNA?
Answer: Perform gastrostomy feedings through a client’s established gastrostomy tube. This
task is within their range of function.
Rationale:
Performing gastrostomy feedings through an established gastrostomy tube is a routine task that
falls within the CNA’s scope of practice, as it involves basic nursing skills. It does not require the
clinical judgment or specialized skills of a nurse and can be safely delegated to a CNA.
49. A nurse manager is preparing an educational session for nursing staff about how to provide
cost-effective care. Which of the following methods should the nurse include in the teaching?
Answer: Delegate non-nursing tasks to ancillary staff.
Rationale:
It is an effective method of providing high-quality, cost-effective care because this will allow
additional time for nurses to focus on skilled tasks.
50. A nurse on an inpatient mental health unit is monitoring a visit between a client who has a
history of aggressive behavior and the client’s partner. Which of the following should the nurse
identify as an indication of potential violence?
Answer: The client is pacing around the chair in which their partner is sitting.
Rationale:
Hyperactivity and pacing indicate that this client is at risk for violent behavior. The nurse should
assess the situation further and attempt to de-escalate the situation by speaking to the client in a
low, calm voice using short sentences.
51. A nurse is caring for a client who has signed an informed consent form to receive
electroconvulsive therapy (ECT). The client states to the nurse, “I’m not sure about this now. I’m
afraid it’s too risky.” Which of the following responses should the nurse make?
Answer: “You have the right to change your mind about this procedure at any time.”
Rationale:
The client can refuse to consent at any time for a procedure. The nurse is demonstrating
advocacy by respecting the client’s wishes regarding care.
52. A rural community health nurse is developing a plan to improve health care delivery for
migrant farmworkers. To identify health services data for this minority group, the nurse should
gather information from which of the following sources?
Answer: Agency for Healthcare Research and Quality
Rationale:
The goal of the Agency for Healthcare Research and Quality (AHRQ) is to improve the quality
of health care services for all populations, including low-income groups and minorities. This data
should help the nurse to develop an evidence-based plan to improve health care services for
specific populations.
53. A nurse is assessing a newborn following a vaginal delivery. Which of the following findings
should the nurse report to the provider?
Answer: Nasal flaring.
Rationale:
This indicates respiratory distress. Signs are nasal flaring, retractions, and grunting.
54. A charge nurse is speaking with the partner of a client. The partner states that the client is not
receiving adequate care. Which of the following actions should the charge nurse take first to
resolve the situation?
Answer: Ask the partner to list specific concerns.
Rationale:
The first action the nurse should take u sing the nursing process is to assess the situation by
asking the partner to list specific concerns.
55. A nurse is providing information to a client immediately before his scheduled Romberg test.
Which of the following statements should the nurse make?
Answer: “I will be checking you once with your eyes open and once with them closed.”
Rationale:
The Romberg test will be performed once with eyes open and once with eyes closed. This is
performed to assess balance and motor function.
56. A nurse is teaching a client who is at 20 weeks of gestation about common discomforts
associated with pregnancy. Which of the following statements by the client indicates an
understanding of the teaching?
Answer: “I will wear a supportive bra overnight.”
Rationale:
Wearing a supportive bra even while sleeping can promote comfort by providing support to
enlarged breasts during pregnancy.
57. A nurse is caring for a client who is taking valproic acid for seizure control. For which of the
following adverse effects should the nurse monitor and report?
Answer: Jaundice.
Rationale:
Monitor the client for jaundice and report any indications to the provider. Clients who take
valproic acid are at risk for liver damage, which can lead to jaundice.
58. A nurse is providing d discharge instructions about newborn care to a client who is
postpartum. Which of the following s statement’s indicates to the nurse that the client
understands the teaching?
Answer: “I will use the bulb syringe first in her mouth and then in her nose”
Rationale:
Newborns are highly susceptible to heat loss. The client should wrap the newborn in a towel
when washing the hair to minimize heat loss.
The client should suction the newborn’s mouth first to remove secretions that the newborn could
aspirate when suctioning the nares.
59. A nurse on a mental h health unit is conducting a mental status e examination (MSE) on a
newly admitted client. Which of the following components of the MSE is the priority for the
nurse to assess?
Answer: Ideas of self-harm.
Rationale:
The greatest risk to this client is injury from ideas of self-harm. The priority assessment the nurse
should make is to determine whether the client has had suicidal or homicidal ideas.
60. A nurse is preparing to administer lactated Ringer’s 1500 mL to infuse at 50 mL/hr. The drop
factor of the manual I V tubing is 15 gtt/min. The nurse should set the manual IV infusion to
deliver how many gtt/min?
Answer: 13 gtt/min
Rationale:
To calculate the flow rate, the nurse uses the formula: volume (mL) ÷ time (min) × drop factor
(gtt/mL). This results in 13 gtt/min for the prescribed infusion rate.
61. A nurse is providing t teaching to a client who has a new diagnosis of type 1 diabetes
mellitus. The nurse should instruct the client to monitor for which of the following findings as a
manifestation of hypoglycemia?
Answer: Irritability
Rationale:
The nurse should instruct the client to monitor for irritability, which can indicate decreased blood
glucose levels.
62. A nurse is providing teaching to a client who is scheduled for ECT. The nurse should inform
the client that which of the following is an adverse effect of ECT?
Answer: Short-term memory loss
Rationale:
This is a common adverse effect of ECT.
63. A charge nurse notices that one of the nurses on the shift frequently violates unit policies by
taking an extended amount of time for a break. Which of the following statements should the
charge nurse make to address this conflict?
Answer: “I would like to talk to you about the unit policies r regarding break time.”
Rationale:
The charge nurse is dealing with the conflict in a cooperative, positive manner by using this
statement to open the conversation in a nonthreatening way. The focus is on the length of the
break time and is not a personal affront.
64. A nurse in an emergency department is caring for a client who is at 9 weeks of gestation and
reports nausea and vomiting for the past 2 days. Which of the following findings should the
nurse expect?
Answer: Urine specific gravity 1.052
Rationale:
The nurse should recognize this urine specific gravity is significantly elevated above the
expected reference range of 1.005 to 1.030. An increased urine specific gravity indicates
dehydration from vomiting.
65. A nurse is caring for an o older adult client who is experiencing chronic anorexia and is
receiving enteral tube feedings. Which of the following laboratory values indicates that the client
needs additional nutrients added to the feeding?
Answer: Albumin 2.8 g/dL
Rationale:
The nurse should recognize that an albumin level of less than 3.5 g/dL indicates malnutrition and
a need for additional nutritional supplementation. The expected reference range for albumin is
3.5 to 5 g/dL.
66. A nurse is conducting g group therapy with clients who have breast cancer. The nurse should
recognize which of the following statements by a client as an example of altruism?
Answer: “I told my doctor that I would like to start a support group for other women who are
sick in my community.”
Rationale:
This statement indicates that the client is demonstrating altruism by reaching out and helping
others.
67. A nurse is providing d dietary teaching to a client who has a new prescription for phenelzine.
Which of the following f food recommendations should the nurse make?
Answer: Broccoli, yogurt, cream cheese
Rationale:
Clients taking an MAOI should not eat foods that contain tyramine. Fermented meat such as
pepperoni and bologna are high in tyramine.
68. A nurse is assessing a client for compartment syndrome. Which of the following findings
should the nurse expect?
Answer: Edema
Rationale:
Compartment syndrome causes increased pain, pallor, and paresthesias from increased edema in
the compartment involved.
69. A nurse is providing d discharge teaching about disease management for a client who has a
new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse’s
priority?
Answer: Ensure that the client understands the medication regimen.
Rationale:
The priority action the nurse should take when using the safety vs risk reduction approach to
client care is to ensure the client understands the medication regimen. The greatest risk to the
client is the potential to develop hypoglycaemia or hyperglycaemia, which can be lifethreatening if treated incorrectly.
70. A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye.
Which of the following r reports by the client should indicate to the nurse that the client has a
detached retina?
Answer: Floating dark spots
Rationale:
These are a manifestation of a detached retina due to bulges, folds, or holes in the affected retina.
71. A nurse on a med-surg u nit is assessing a client who has had a stroke. For which of the
following findings should the nurse initiate a referral for occupational therapy?
Answer: Difficulty performing ADLs
Rationale:
A referral for occupational therapy to teach the client the skills necessary to become independent
in performing ADLs such as bathing, dressing, and eating.
72. A nurse is assessing a client following a colonoscopy. Which of the following findings should
indicate to the nurse that the client is haemorrhaging?
Answer: Rapid decrease in blood pressure
Rationale:
This is an indication of haemorrhage.
73. A nurse is caring for a client who recently signed an informed consent form to donate a
kidney to her sibling who had end-stage kidney disease. The donor states to the nurse, “I don’t
want my brother to die, but what if I need this kidney one day?” Which of the following
responses should the nurse make?
Answer: “You’re afraid that your other kidney will fail at some point after the organ donation?”
Rationale:
The nurse is restating the client’s statement, w which lets the client know that the nurse is
listening and paying attention to what the client is communicating.
74. A nurse is assessing a client who has pulmonary edema. Which of the following findings
should the nurse expect?
Answer: Pink, frothy sputum
Rationale:
A client who has manifestations of pulmonary edema can have pink, frothy sputum due to fluid
leaking across the pulmonary capillaries and into the lung tissue.
75. A nurse administers an incorrect dose of medication to a client. The nurse recognizes the
error immediately and completes an incident report. Which of the following facts related to the
incident should the nurse document in the client’s medical record?
Answer: Time the medication was given
Rationale:
The nurse should document the time, the name of the med, the dose, and the route in which the
med was given on the client’s MAR immediately after it was administered. The nurse should also
document the time that the incorrect med was administered to the client in the incident report, as
this is a fact directly related to the occurrence.
76. A nurse is caring for a client who is post-op after receiving moderate (conscious) sedation.
The client suddenly becomes restless and reports feeling lightheaded. Which of the following
actions should the nurse take?
Answer: Check the client’s oxygen saturation level.
Rationale:
Restlessness and light headedness are indications of hypoxia. The nurse should check the client’s
oxygen saturation level.
77. A nurse in an ED is assessing a school-aged child who was brought in by their parents and
has scald burns to both hands and wrists. The nurse suspects physical abuse. Which of the
following actions should the nurse take?
Answer: Contact Child Protective Services
Rationale:
The nurse has a legal responsibility to report suspected physical abuse to Child Protective
Services.
78. A nurse is caring for a 2-month-old infant who has Hirschsprung disease (HD). Which of the
following areas should the nurse assess for manifestations of HD?
Answer: The nurse should assess the infant’s abdomen for distention and visible peristalsis,
which are manifestations of HD.
Rationale:
Hirschsprung disease (HD) causes a lack of ganglion cells in the colon, leading to impaired
motility and resulting in abdominal distention and visible peristalsis. These signs are common
manifestations of HD in infants and should be carefully assessed.
79. A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states,
“My family does not care whether I live or die.” Which of the following responses should the
nurse make?
Answer: “How does this make you feel?”
Rationale:
This response encourages the client to evaluate their feelings.
80. A nurse is providing discharge teaching for the parents of a preschool-age child who has a
new prescription for amoxicillin/clavulanate suspension. Which of the following instructions
should the nurse include in the teaching?
Answer: Shake the medication bottle well before each dose is given.
Rationale:
Store the medication in the refrigerator
Report diarrhea to the provider immediately
81. A nurse on a med surg unit is caring for a client who has a new diagnosis of terminal cancer.
The client tells the nurse that they would like to go home to be with family and loved ones.
Which of the following actions should the nurse take?
Answer: Make a referral for social services
Rationale:
As a client advocate, the nurse should support the client’s decisions and obtain a referral for
social services to ensure that the client’s needs a t home are met. Social services can set up home
care or hospice care services for the client if needed.
82. A nurse is assessing a client who has a chest tube. Which of the following findings should the
nurse expect?
Answer: Occlusive dressing on the insertion site.
Rationale:
This prevents air from leaking and is an expected finding.
83. A nurse is preparing to transfer a client who has had a stroke to a rehabilitation facility. The
client’s family tells the nurse they are concerned about the level of care the client will receive.
Which of the following actions should the nurse take?
Answer: Facilitate an interdisciplinary conference at the new facility for the family.
Rationale:
This will address the family’s concerns about providing optimal care for the client.
84. A nurse is assessing a client who has major depressive disorder and is taking amitriptyline.
Which of the following should the nurse identify as an adverse effect of the medication?
Answer: Blurred vision
Rationale:
This is an adverse effect of amitriptyline and the provider should be notified.
85. A charge nurse is providing an educational session about infection control for a group of staff
nurses. Which of the following statements by one of the staff nurses indicates an understanding
of isolation precautions?
Answer: “A client who requires airborne precautions should be placed in a negative-pressure
airflow room.”
Rationale:
Airborne precautions require a negative-pressure airflow room that has at least 6-12 air
exchanges each hour using a HEPA filtration system.
86. A nurse is preparing to administer a blood transfusion to a client. Which of the following
procedures should the nurse follow to ensure proper client identification?
Answer: Verify the client and blood product information with another licensed nurse.
Rationale:
The nurse should compare the blood product label against the medical record and the client’s
identification number with another nurse to ensure the correct blood product is administered to
the correct client.
87. A nurse in a mental health clinic is assessing a client who has a history of seeking counseling
for relationship problems. The client shows the nurse multiple superficial self-inflicted
lacerations on their forearms. The nurse should identify these behaviours as characteristics of
which of the following personality disorders?
Answer: Borderline
Rationale:
The nurse should identify that clients who have borderline personality disorder tend to be
emotionally unstable, have troubled interpersonal relationships, and often engage in harmful
behaviours such as cutting, substance use, and suicidal ideation.
88. A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain
after falling off a step stool at home. Which of the following prescriptions should the nurse
clarify with the provider?
Answer: Apply a cold pack to the client’s ankle for 30 min/hr
Rationale:
The nurse should clarify a prescription for a cold pack to the client’s ankle because type 1
diabetes mellitus is a contradiction for receiving cold therapy. A client who has type 1 diabetes
mellitus can have impaired circulation due to arteriosclerosis and a loss of sensory perception
due to neuropathy. Ice can further impair circulation.
89 A nurse is teaching about adverse effects with a client who is s tarting to take captopril. Which
of the following findings should the nurse identify a s an adverse effect of the medication to
report to the provider?
Answer: Cough
Rationale:
This is due to the buildup of bradykinin in the lungs. The client should report this to the provider.
90. A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60 mm
Hg. and HCO3 of 25 mEq/L. The nurse should identify that the client has which of the following
acid-base imbalances?
Answer: Respiratory acidosis
Rationale:
A client who has respiratory acidosis will have decreased pH below the expected reference range
of 7.35-7.45, an increased PaCO2 above the expected reference range of 35-45 mm Hg, and an
HCO3 within the expected reference range of 22-26 mEq/L.
91. A nurse in a provider’s office is assessing an adolescent who has been taking ibuprofen for 6
months to treat juvenile idiopathic arthritis. Which of the following questions should the nurse
ask to assess for an adverse effect of this med?
Answer: “Have you had any stomach pain or bloody stools?”
Rationale:
These are an indication of gastrointestinal bleeding, an adverse effect of ibuprofen.
92. A nurse in a paediatric unit has received a change-of-shift report for four children. Which of
the following children should the nurse assess first?
Answer: A 10-year-old child who is awaiting surgery f or an appendectomy and experienced
sudden relief from pain.
Rationale:
Using the urgent vs nonurgent approach to client care, the nurse should determine that the client
to assess first is the child awaiting an appendectomy who suddenly experiences pain relief as this
can be an indication of peritonitis from a ruptured appendix. The nurse should notify the provider
immediately.
93. A nurse on an inpatient u nit is caring for a client who has schizophrenia and recently started
taking risperidone. Which of the following actions should the nurse take?
Answer: Implement fall precautions for the client.
Rationale:
Risperidone can cause orthostatic hypotension and dizziness, which can lead to falls. The nurse
should initiate fall precautions for the client.
94. A nurse is assessing a client who has decreased visual acuity due to cataracts. The nurse
should identify which of the following physiological changes is the cause of the client’s visual
loss?
Answer: Increased opacity of the lens
Rationale:
A cataract is a cloudy or opaque area in the lens of the eye that inhibits light penetration.
95. A nurse is caring for a client following a vacuum-assisted birth. The nurse should monitor the
client for which of the following complications related to vacuum-assisted birth?
Answer: Cervical laceration
Rationale:
Complications are perineal, vaginal, or cervical lacerations.
96. A nurse is updating the plan of care for a client who is 48 hr. post-op following a
laryngectomy and is unable to speak. which of the following actions should the nurse plan to
take first?
Answer: Determine the client’s reading skills
Rationale:
Using the nursing process to assess the client, determine the client’s level of reading skills and
cognition. The nurse can best provide the client with a variety of customized techniques to
practice and use after verbal skills are lost.
97. A nurse is caring for a school-aged child who has dehydration and is receiving an oral
rehydration solution. Which of the following lab results indicates that the treatment regimen is
effective?
Answer: Serum sodium 138 mEq/L
Rationale:
Sodium level of 138 mEq/L, is within the expected reference range of 136-145 mEq/L and is an
indication that the child is responding to the oral rehydration solution.
98. A school nurse is notified of an emergency in which several children were injured following
the collapse of playground equipment. Upon arrival at the playground, which of the following
actions should the nurse take first?
Answer: Survey the scene for potential hazards to staff and children.
Rationale:
Using the nursing process, assess the situation. By surveying the scene, the nurse can identify
potential hazards to staff and children. These findings allow the nurse and staff to enter the scene
and safely provide care to injured children and help decrease the risk of further injury.
99. A nurse in an ED is caring for a client who is unconscious and requires emergency medical
procedures. The nurse is unable to locate members of the client’s family to obtain consent.
Which of the following actions should the nurse take?
Answer: Proceed with provision for medical care.
Rationale:
When a client is unable to give informed consent in an emergency, health care personnel can
proceed with necessary life-saving care because the law considers this implied consent.
100. A nurse is caring for a school-aged child who is taking valproic acid. The nurse should
expect the provider to order which of the following diagnostic tests?
Answer: Serum liver enzyme levels.
Rationale:
Valproic acid can cause hepatic toxicity. The nurse should expect the provider to prescribe lab
tests to assess the child’s liver function prior to and periodically during therapy.
101. A nurse manager is preparing to teach a group of newly licensed nurses about effective time
management. Which of the following steps of the time management process should the nurse
manager include as the priority?
Answer: Making a list of activities to complete.
Rationale:
According to evidence-based practice, planning is the most important step in managing time
effectively. The nurse manager should include making a list of activities to complete as the
priority. Other planning activities include setting goals, establishing priorities, and scheduling
activities.
102. A nurse is caring for a client who has a pulmonary embolism. The client is receiving heparin
via continuous IV infusion at 1200 units/hr and warfarin 5 mg PO daily. The morning lab values
for the client are aPTT 98 seconds and INR 1.8. Which of the following actions should the nurse
take?
Answer: Withhold the heparin infusion.
Rationale:
The expected value for aPTT is 40 seconds. A therapeutic level of heparin increases the aPTT by
a factor of 1.5-2, making the aPTT 60-80 seconds. An aPTT level of 98 is above the expected
reference range, indicating that the dosage should be reduced, or the infusion withheld until the
aPTT returns to the therapeutic range.
103. A nurse is providing teaching to a school-age child who has asthma about using an albuterol
metered-dose inhaler. Which of the following instructions should the nurse include?
Answer: Take the medication 15 mins before playing sports.
Rationale:
Take 5-20 min prior to exercise to promote bronchodilation. The meds effects begin immediately,
peak in 30-60 min, and can last for up to 5 hr.
104. A home health nurse is evaluating a school aged child who has cystic fibrosis. The nurse
should initiate a request for a high-frequency chest compression vest in response to which of the
following parent statements?
Answer: “My child has only a small amount of mucus after percussion therapy.”
Rationale:
The nurse should recommend a high-frequency chest compression vest for a child who has
inadequate results from other airway clearance therapy techniques. Older children often require
other techniques in addition to percussion and postural drainage to achieve adequate mucus
expectoration.
105. A nurse is planning care for a patient who is receiving chemotherapy and has neutropenia.
Which of the following interventions should the nurse include in the plan?
Answer: Avoid including raw fruits in the client’s diet.
Rationale:
This reduces the risk of bacterial infections.
106. A nurse is caring for a client who is in the fourth stage of labor and is receiving oxytocin via
continuous IV infusion. Which of the following assessments is the nurse’s priority?
Answer: Amount of vaginal bleeding.
Rationale:
The first action the nurse should take u sing the nursing process is assessing the amount of
vaginal bleeding. A client who is in the fourth stage of labor is at risk for haemorrhage, so
assessing the amount of vaginal bleeding is the nurse’s priority.
107. A nurse is caring for a client who is in the resuscitation phase of burn injury. Which of the
following findings should the nurse expect?
Answer: Hyponatremia
Rationale:
The nurse should expect a decrease i n sodium levels because sodium is drawn to the edematous
burn areas and lost through plasma leakage.
108. A nurse is teaching a client who has a new prescription for total parenteral nutrition through
a central line. Which of t he following information should the nurse include in the teaching?
Answer: “I will need to measure your weight daily.”
Rationale:
The nurse should instruct the client that daily w eight measurement is a necessary part of
administering nutrition through a central line to avoid fluid overload and monitor for adequate
weight gain.
109. A nurse is assessing a client who has bipolar disorder. Which of the following alterations in
speech is the client u sing?
Answer: Flight of ideas.
Rationale:
Flight of ideas is an alteration in speech in which the speaker talks continuously with sudden,
frequent topic changes.
110. A home health nurse is caring for a group of older adult clients. The nurse should initiate a
referral to the Program o f All-Inclusive Care for the Elderly (PACE) for which of the following
clients?
Answer: A client whose caregiver requests adult daycare services.
Rationale:
The nurse should initiate a referral for PACE for this client because PACE provides adult day
care services along with in-home assessments and supportive services.
111. A nurse at a mental health clinic is caring for four clients. The nurse should recognize that
which of the following clients is using dissociation as a defense mechanism?
Answer: A client who was abused as a child describes the abuse as if it happened to someone
else.
Rationale:
The nurse should identify that this client i s using the defense mechanism of dissociation because
they are separating painful events from t he conscious mind and describing the events as if they
happened to another person.
112. A nurse is caring for a client who has active pulmonary tuberculosis. Which of the following
actions should the nurse take?
Answer: Assign the client to a private room with negative air pressure.
Rationale:
To control the spread of active TB, the nurse should assign the client to a private room with
negative air pressure.
113. A nurse is providing t teaching to a client who is at 24 weeks of gestation and is scheduled
for a 3 hr oral glucose tolerance test. Which of the following instructions should the nurse
include in the teaching?
Answer: “You will need to fast the night before the test.”
Rationale:
The nurse should instruct the client that they will need to fast the night before the test to prevent
inaccurate test results.
114. A nurse is providing e education to the parent of a school-age child who has asthma. Which
of the following statements by the parent indicates an understanding of the teaching?
Answer: “I will make sure my child receives a yearly influenza immunization.”
Rationale:
Children who have asthma should be immunized and protected from infections. The nurse should
educate the parent to ensure the child receives a yearly influenza immunization.
115. A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the
following lab tests should the nurse review prior to adjusting the client’s heparin?
Answer: aPTT
Rationale:
Prior to adjusting the client’s continuous heparin infusion, the nurse should review the client’s
activated partial thromboplastin (aPTT). T he expected reference range for the aPTT is 40 secs.
Clients who are receiving continuous heparin therapy should have an aPTT of 60-80 secs, which
is 1.5-2 times the expected aPTT level. The nurse should increase or decrease the heparin
infusion according to this value.
116. A nurse is assessing a client who is taking propranolol. Which of the following findings
should indicate to the nurse that this client is experiencing an adverse reaction to propranolol?
Answer: Wheezing
Rationale:
The nurse should recognize that wheezing can indicate the client is experiencing an adverse
reaction to the med.
117. A client is receiving IV fluids at 150 m L/hr. Which of the following findings indicates that
the client is experiencing fluid overload?
Answer: Dyspnea
Rationale:
The nurse should recognize that dyspnea indicates the client could be experiencing fluid
overload. Fluid overload can lead to the backup of fluid in the pulmonary system resulting in
shortness of breath.
118. A nurse is assessing a client whose partner recently died. The client states, “I don’t know
what to do without my partner. Life is just not worth living.” Which of the following responses
should the nurse make?
Answer: “You seem to be having a difficult time right now.”
Rationale:
This statement makes an observation, which is a therapeutic response by the nurse. It encourages
the client to express their thoughts and feelings.
119. A nurse must recommend clients for discharge in order to make room for several critically
injured clients from a local disaster. Which of the following clients should the nurse recommend
discharge?
Answer: A client who has cellulitis and is receiving oral antibiotics every 8 hr.
Rationale:
This client can safely continue this treatment at home.
120. A nurse is performing an admission assessment on a client who had a recent positive
pregnancy test. The first day of her last menstrual period (LMP) was May 8. According to
Nagele’s rule, which of the following dates should the nurse document as the client’s estimated
date of birth (EDB)?
Answer: February 15.
Rationale:
Add 7 days to the first day of the client’s LMP and then subtract 3 months.
121. A nurse is providing teaching about home care to the parents of a child who has autism
spectrum disorder. Which of the following instructions should the nurse include? Use a rewards
system to modify the child’s behavior.
Answer: Use a rewards system to modify the child’s behavior.
Rationale:
Children who have autism spectrum disorder respond well to a reward system, which can
provide structure and expectations for behavior.
122. A nurse in a provider’s office is caring for an 18-month-old toddler who has a blood level of
3 mcg/dL. Which of the following actions should the nurse take?
Answer: Recommend rescreening in 1 year.
Rationale:
This level is within the expected reference range.
123. A nurse is caring for a client who has cancer and is deciding between two treatment plans.
The client asks the nurse for assistance in making the decision. Which of the following responses
should the nurse make?
Answer: “Tell me more about your understanding of the options.”
Rationale:
This is therapeutic because it is offering a general lead that facilitates communication between
the nurse and the client and will help the nurse to explore the client’s feelings about the treatment
options.
124. A nurse is caring for a client who has a new prescription for clonidine. The nurse should
inform the client that which of the following findings is an adverse effect of this med?
Answer: Dry mouth.
Rationale:
Clonidine is an indirect-acting antiadrenergic agent used for HTN, severe pain, and ADD. The
nurse should inform the client that dry mouth, or xerostomia, is a common adverse effect of this
med.
125. A nurse is creating a plan of care for a client who has left-sided weakness following a
stroke. Which of the following interventions should the nurse include in the plan?
Answer: Support the client’s left arm on a pillow while sitting.
Rationale:
This prevents the extremity from hanging freely because this can cause shoulder subluxation.
126. A nurse is caring for a client who has acute blood loss following a trauma. The client refuses
a blood transfusion that might potentially save their life. Which of the following actions should
the nurse take first?
Answer: Explore the client’s reasons for refusing the treatment.
Rationale:
This is assessment. The nurse should gather more data regarding the client’s decision to refuse
the blood transfusion.
127. A nurse is performing an abdominal assessment on a client. Identify the sequence of actions
the nurse should take.
Answer: Inspection, auscultation, percussion, palpation
Rationale:
Inspect to assess skin integrity and symmetry. Auscultate. Percuss for tympany, dullness, absence
or flatness of resonance. Palpate for tenderness, pain, or the presence of a mass.
128. A nurse is providing teaching to the guardians of a newborn about measures to prevent
sudden infant death syndrome (SIDS). Which of the following guardian statements indicates an
understanding of the teaching?
Answer: “I will not allow anyone to smoke near my baby.”
Rationale:
Research indicates a strong correlation between exposure to cigarette smoke and the occurrence
of SIDS.
129. A nurse is preparing a sterile field to perform a sterile dressing change. Which of the
following interventions should the nurse use to maintain surgical aseptic technique?
Answer: Maintain sterile objects with the line of vision.
Rationale:
Objects out of the line of vision are not considered sterile. Keep sterile items at least 1 inch
(2.5cm) away from the border of a sterile drape. Hold gloved hands away from the body and
above waist level to prevent contamination.
130. A nurse is caring for a client who has a magnesium level of 2.7 mEq/L. Which of the
following interventions should the nurse plan to take?
Answer: Initiate continuous cardiac monitoring.
Rationale:
This client is at risk for cardiac dysrhythmias and cardiac arrest.
131. A nurse is assessing a client who is at 11 weeks of gestation and reports drinking ginger tea.
Which of the following findings indicates the client’s use of ginger tea is effective?
Answer: The client reports a decrease in episodes of nausea.
Rationale:
The client can also use ginger ale and ginger snaps to alleviate nausea associated with pregnancy.
132. A nurse is caring for a client who has a deep vein thrombosis. Which of the following
actions should the nurse take?
Answer: Instruct the client to elevate the affected extremity when sitting.
Rationale:
Reduce edema and facilitate venous return. Elevating the affected extremity helps reduce edema
and promotes venous return, minimizing complications and improving circulation in clients with
deep vein thrombosis.
133. A nurse is preparing to replace a client’s transdermal fentanyl patch after 72 hours of use.
After the nurse opens the packet containing the new patch, the client declines to accept it. Which
of the following actions should the nurse take?
Answer: Ask another nurse to witness the disposal of the new patch.
Rationale:
Place the med in a secure receptacle, according to agency policy, when disposing of any unused
portion of a controlled substance.
134. A nurse is assessing a n older adult client who has pneumonia. Which of the following
findings should the nurse expect?
Answer: Acute confusion.
Rationale:
Will have acute confusion, fatigue, lethargy, and anorexia.
135. A nurse is providing client teaching about the basal body temp method of birth control.
Which of the following information should the nurse include in the teaching?
Answer: “Your body temp might decrease slightly just prior to ovulation.”
Rationale:
A decrease of 1° F commonly occurs immediately prior to ovulation.
136. A nurse manager in a long term facility is having difficulty with staffing for weekend shifts
and is planning to implement some changes to the scheduling procedure. Which of the following
actions should the nurse manager take first?
Answer: Form a committee of staff members to investigate current staffing issues.
Rationale:
Assess the staffing issue. The first stage of change is the “unfreezing stage,” in which
information is gathered about the problem. The first action the nurse manager should take is to
form a committee to investigate the problem.
137. A nurse is preparing to administer an IM injection to a client who is obese. Which of the
following actions should the nurse plan to take?
Answer: Use the ventrogluteal site.
Rationale:
It has a thick area of muscle and contains no large nerves or blood vessels.
138. A hospice nurse is consulting with a client and her family about receiving home services.
Which of the following statements should the nurse identify as an indication that the family
understands home hospice care?
Answer: “We can expect the hospice nurse to provide support for us after our mother’s death.”
Rationale:
Hospice care includes bereavement services after a family member’s death.
139. A nurse is caring for a client who is receiving positive end-expiratory pressure (PEEP) via
mechanical ventilation. The nurse should monitor the client for which of the following adverse
effects of PEEP?
Answer: Tension pneumothorax
Rationale:
The nurse should identify that tension pneumothorax is a possible adverse effect of PEEP. The
nurse should monitor the client’s lung sounds hourly for indications of a tension pneumothorax,
such as tracheal deviation, absent breath sounds, and distended neck veins.
140. A nurse manager is reviewing the client’s rights with the nurses on the unit. The nurse
manager should tell the nurses that informed consent promotes which of the following ethical
principles? Autonomy
Answer: Autonomy refers to a client’s ability to make their own decisions about treatment.
Rationale:
Informed consent promotes autonomy by providing clients with complete information about
treatment.
141. A nurse preceptor is evaluating the performance of a newly licensed nurse. Which of the
following actions by the newly licensed nurse requires intervention by the preceptor?
Answer: Starts a task then determine what supplies are needed.
Rationale:
The preceptor should intervene and instruct the newly licensed nurse to gather supplies before
performing client tasks to practice effective time management.
142. A nurse manager is preparing an educational session about advocacy for a group of nurses.
The nurse manager should include which of the following information in the teaching?
Answer: Advocacy is a leadership role that helps others to self-actualize.
Rationale:
The nurse manager should teach that advocacy is a leadership role that can help others to grow
personally and professionally through self-actualization.
143. A nurse is admitting a client who has pneumonia. The nurse should initiate which of the
following isolation precautions for the client?
Answer: Droplet
Rationale:
The nurse should initiate droplet precautions for this client by placing the client in a private room
and wearing a surgical mask when caring for the client. Pneumonia is transmitted by droplet
particles.
144. A nurse has just received change of shift report on four clients. Which of the following
clients should the nurse assess first?
Answer: A client who is postoperative with abdominal distention and no bowel sounds.
Rationale:
Using the acute vs chronic approach to client care, the nurse should first assess the client who is
postoperative with abdominal distention and no bowel sounds because these manifestations are
an indication of paralytic ileus.
145. During a change of shift report, a night shift nurse informs the day shift nurse that a newly
admitted client was disoriented and combative during the night. Which of the following actions
should the day shift nurse take?
Answer: Move the client to a room near the nurses’ station.
Rationale:
The day shift nurse should move the client to a room near the nurses’ station to enhance the
staff’s ability to keep the client under frequent observation.
146. A nurse is reviewing the laboratory results of a toddler who has hemophilia A. Which of the
aPTT values should the nurse expect?
Answer: 45 seconds
Rationale:
This value is above the expected reference range of 30-40 seconds and indicates a risk for
spontaneous bleeding, which is a manifestation of hemophilia A.
147. A nurse is planning care for a client who has rheumatoid arthritis. Which of the following
interventions should the nurse include in the plan?
Answer: Increase the client’s dietary iron intake.
Rationale:
Clients who have rheumatoid arthritis require foods high in protein, vitamins, and iron to
promote tissue repair. The nurse should encourage the client to increase their intake of dietary
iron.
148. A nurse is an outpatient mental health facility is assessing a child who has autism spectrum
disorder. Which of the following manifestations should the nurse expect?
Answer: Strict adherence to routines
Rationale:
The nurse should identify that a child who has autism spectrum disorder can exhibit strict
adherence to routines or rituals, a fixation to specific objects, and resistance to change.
149. A nurse is caring for a client who had a stroke 6 hr ago. Which of the following
interventions should the nurse implement to reduce the risk of increased intracranial pressure
(ICP)?
Answer: Place the client in a quiet environment.
Rationale:
The nurse should keep the client’s environment quiet to minimize the risk of increasing ICP.
