ATI Comprehensive Practice Exam
A nurse is caring for a client who is experiencing a diazepam overdose. Which of the following
medication should the nurse administer?
Answer: Flumazenil
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?
Answer: Shivering
A nurse is planning care for a client who sustained a major burn over 20% of the body. Which of
the following interventions should the nurse include to support the client’s nutritional
requirements
Answer: Keep a calorie count for foods and beverages
A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via
continuous IV infusion. Which of the following actions should the nurse plan to take?
Answer: Protect the IV bag from exposure to light
A nurse is caring for a client who is recovering from an amputation for her right arm below the
elbow. Which of the following information should the nurse report to the occupational therapist
Answer: The nurse should report the client’s level of independence in performing daily activities
to the occupational therapist.
A nurse is caring for a client who has cancer of the throat and is receiving radiation therapy. The
nurse should monitor for which of the following findings as an adverse effect of the radiation?
Answer: Altered taste sensation
A nurse in an intensive care unit is assessing a client who has heart failure and has been receiving
metoprolol for 3 days. Which of the following findings indicates the treatment has been
effective?
Answer: Decreased edema
A nurse is admitting a client who has schizophrenia and experiences occasional auditory
hallucinations. The client states “It’s hard not to listen to the voices” which of the following
questions should the nurse ask the client?
Answer: What helps you ignore what you are hearing?
A nurse is preparing to administer cefpodoxime 10 mg/kg/day PO divided equally every 12 hr to
a child who weighs 66lbs. available is cefpodoxime 20 mg/ml oral solution. How many ml
should the nurse administer per dose?
Answer: 7.5
A nurse is teaching a client who has chronic urinary tract infections. Which of the following
instructions should the nurse include?
Answer: Try to void every 4 hr
A nurse is assessing the coping strategies of a client who has recently retired. Which of the
following statements by the client indicates that the client is using compensation as a defense
mechanism?
Answer: Since I retired I have entered many gardening compensations
A nurse is caring for a client who is recovering from an amputation of her right arm below the
elbow. Which of the following information should the nurse report to the occupational therapist?
Answer: The client has two small children at home
A nurse is providing 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?
Answer: Maternal serum alpha fetoprotein
A nurse is planning care for a client who is 3 days postoperative following a below the knee
amputation. Which of the following actions should the nurse include in the plan?
Answer: Assist the client to a prone position once a day for 1 hr
A nurse is assessing a client who is pregnant and has new diagnosis of hyperemesis gravidarum.
Which of the following findings should the nurse expect?
Answer: Elevated blood pressure
A nurse is providing discharge teaching to a client who has type 1 dm about preventing diabetic
ketoacidosis when ill. Which of the following statements by the client indicates an understanding
of the teaching?
Answer: I will call my doctor if I am sick
A nurse is caring for a client who has schizophrenia and is experiencing delusions. Which of the
following actions should the nurse take?
Answer: Encourage the client to rest quietly in bed twice per day
A nurse is teaching a wellness class about depression for a group of older adults clients. Which
of the following information should the nurse include in the teaching?
Answer: Depression can be misdiagnoses as a neurocognitive disorder in older adult clients
A nurse is preparing for discharge information for a client who has type 2 dm. which of the
following information resources should the nurse provide to the client?
Answer: Food exchange lists for meal planning from the American diabetes association
A nurse is preparing to perform a heel stick on an infant. Which of the following actions should
the nurse plan to take to reduce the infant’s pain during the procedure?
Answer: Promote skin to skin contact with the infants guardian during the procedure
A nurse is administering a continuous enteral feeding to a client.
Which of the following actions should the nurse take?
Answer: Check gastric residuals every 4 hr
A nurse is preparing to obtain a clients signature on an informed consent form. Which of the
following actions should the nurse take first?
Answer: Ask the client to explain his understanding of the procedure
A nurse is preparing to obtain a client’s signature on an informed consent. Which of the
following actions should the n take first ?
Answer: Witness the client signing the informed consent form
A nurse is planning care for a client who is receiving continuous enteral tube feedings through an
open system, which of the interventions should the nurse include in the plan of care?
Answer: Place enough formula in the container to last 18 hours
A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the following
clients should the nurse see first?
Answer: A client who has preeclampsia and reports a persistent headache
A nurse is providing discharge teaching for the guardian of a school age child following a cardiac
catheterization instructions should the nurse include in the teaching?
Answer: You should remove your child’s pressure dressing tomorrow
A nurse in an emergency department is caring for a 3 year old child who has suspected epiglottis.
Which of the following actions should the nurse take?
Answer: Obtain a throat culture
A nurse is preparing to provide discharge teaching to a client who is newly diagnoses with
diabetes mellitus. Which of the following statements by the client indicates a readiness to learn?
Answer: I’d like to wait until my partner is here so that we can both learn together
A home health nurse is preparing to make an initial visit to a family following a referral from a
local provider. Identify the sequence of steps the nurse should take when conducting a home
visit.
Answer: • Clarify the reason for the referral with the providers office
• Contact the family to determine availability and readiness to make an appointment
• Identify family needs and interventions using the nursing process
• Discuss plans for future visits with the family
• Record information about the home visit according to agency policy
A nurse is teaching a guardian of an adolescent who has mild persistent asthma and a new
prescription for maintenance prednisone. Which of the following statements by the guardian
indicates an understanding of the teaching?
Answer: This medication can increase my son’s risk for infection.
A nurse is using an IV pump for a newly admitted client. Which of the following actions should
the nurse take?
Answer: Check the cords of the IV pump for fraying
A nurse is assessing a client who is receiving daily aspirin therapy. The nurse should identify that
which of the following findings might indicate an allergic reaction to this medication?
Answer: Blurred vision
A nurse manager is developing a protocol for staff discipline. Which of the following actions
should the nurse manager take when implementing this new protocol?
Answer: Inform staff about the purpose of the units new processes
A nurse is caring for a 1 month old infant who has manifestation of severe dehydration and a
prescription for parenteral fluid therapy the guardian asks: what are the indications that my baby
needs an IV?” which of the following responses should the nurse make?
Answer: Your baby needs an IV because she is not producing tears
A nurse on a mental health unit is planning room assignments for four clients. Which of the
following clients should the nurse assign to a room near the nurses station?
Answer: A client who has a depressive disorder and reports feeling hopeless.
A nurse is performing an abdominal assessment as part of a clients comprehensive physical
examination. Which of the following is the final step the nurse should perform?
Answer: Palpation
A nurse is teaching a client who is pregnant and has a new prescription for an iron supplement.
Which of the following statements should the nurse include?
Answer: You might become constipated while taking this medication
A nurse is teaching a client who is receiving radiation therapy about skin protection. Which of
the following client statements understanding of the teaching?
Answer: I will use my hand instead of a washcloth to was the irradiated area of skin
A nurse is caring for a client who is 4 hr postpartum. The client reports an urge to void but is
unable to void. Which of the following actions should the nurse take?
Answer: Massage the clients fundus
A nurse is preparing educational material for a client. Which of the following techniques should
the nurse use in creating the material?
Answer: Write information at a seventh grade reading level
A nurse is reviewing laboratory findings for a client who is receiving TPN. For which of the
following findings should the nurse notify the provider?
Answer: Sodium 125 mew/L
A nurse is providing discharge teaching to a client who is postoperative following surgery for
carpal tunnel syndrome. Which of the following statements by the client indicates an
understanding of the teaching?
Answer: I will needs to keep my hand elevated above my heart for several days
A nurse is planning care for a client who has an L4 spinal cord injury. Which of the following
interventions to prevent skin breakdown should the nurse include in the plan of care?
Answer: Ask the client to shift his weight every 20 mins while sitting in a chair
A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an 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?
Answer: Assault
A nurse is caring for a client who reports insomnia. Which of the following is the priority for the
nurse to report to the provider?
Answer: Snores loudly at night with morning headaches
A nurse is teaching a client who has heart failure about engaging in an exercise program. Which
of the following statements by the client indicates an understandings of the teaching?
Answer: I will make sure I can still talk while exercising
A nurse is assessing a client who has anorexia nervosa. Which of the following findings indicates
effectiveness of the treatment plan?
Answer: The client gains a total of 0.9 kh (2 lbs) during the first month
A nurse is assessing a client to determine the needs for physical restraints. The nurse should
identify which of the following as an acceptable reason to apply physical restraints.
Answer: To maintain the patency of an IV line
A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a
kidney transplant. Which of the following findings should the nurse report to the provider?
Answer: Serum creatinine 1.6
A nurse is planning a community health program about Parkinson’s disease, which of the
following interventions should the nurse include as a tertiary prevention strategy?
Answer: Provide daily exercise classes to improve ambulation for clients who have Parkinson’s
disease
A nurse is creating a plan of care for a newly admitted client who has obsessive compulsive
disorder. Which of the following interventions should the nurse include?
Answer: Allow the client enough time to perform rituals
A nurse is teaching a client who has alcohol use disorder about disulfiram. Which of the
following client statements indicates an understanding of the teaching?
Answer: I should avoid products containing alcohol, like mouthwash, while taking the
medication
A nurse is assessing a client who has type 1 diabetes melilites and was administered insulin
lispro 1 hr ago. Which of the following manifestations indicates that the client might be
experiencing hypoglycemia?
Answer: Confusion
A nurse is preparing to initiate intravenous fluids via infusion pump for a client. Which of the
following actions should the nurse take?
Answer: Check the expiration date on the safety inspection sticker of the pump
A nurse is caring for a client who will undergo a procedure. The client states he does not want to
provider to discuss the results with his partner . which of the following is an appropriate response
for the nurse to make?
Answer: You have the right to decide who receives information
A nurse is caring for a client who is obese. The client is crying and states “everyone is staring at
me because of my weight.” Which of the following responses should the nurse make?
Answer: Is sounds like you’re saying that you feel uncomfortable around others
A nurse is teaching a group of clients at a community health fair about genetic risks for diseases.
Which of the following statements by a client indicates an understanding of the teaching?
Answer: My family has a genetic risk for breast cancer, so I am considering a total mastectomy
A nurse manager is planning a performance evaluation for a staff nurse. Which of following
actions should the nurse manager take?
Answer: Establish goals for improvement with the staff nurse
A nurse is caring for a client who has acute glomerulonephritis. The nurse should identify that
which of the following findings is the priority?
Answer: BUN 24
A nurse is teaching participants at a community center about advance directives. Which of the
following information should the nurse include in the teaching?
Answer: A heath care surrogate makes health care decisions when the client is no longer able
A nurse is instructing a school age child who has asthma about the use of a peak expiratory flow
meter. Which of the following instructions should the nurse include in the teaching?
Answer: Blow into the meter as hard and quickly as possible
A nurse is caring for a client who is postoperative and has a chest tube drainage system. For
which of the following findings should the nurse notify the provider?
Answer: Continuous bubbling in the water seal chamber
A nurse is planning care for a client who is receiving haemodialysis. Which of the following
actions should the nurse include in the plan of care?
Answer: Check the vascular access site for bleeding after dialysis
A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if
the medications can be given 2 hr earlier. Which of the following statements should the nurse
make?
Answer: I can start the medication 30 minutes earlier
A nurse is preparing to administer a medication that is available in a glass ampule. Which of the
following actions should the nurse plan to take?
Answer: The nurse should use a filter needles to withdrawal the medication
A nurse is caring for a client who had heart failure. For which of the following lab values should
the nurse withhold the client’s morning dose of digoxin and contact the provider
Answer: Potassium 3.2
A nurse is assessing a client who had an uncomplicated vaginal birth 3 days ago. In which of the
following locations should the nurse expect to palpate the clients fundus?
Answer: C (lowest one)
A nurse is planning care for a client who is Chinese American and reports adhering to Chinese
culture postpartum practices. Which of the following should the nurse anticipate?
Answer: Prefers foods that maintain a balance of hot and cold within the body
A nurse is caring for a client who speaks a language different from the nurse. Which of the
following actions should the nurse take?
Answer: use a facility-based interpreter of the same sex as the client
A charge nurse on a medical surgical unit is planning assignments for a LPN who has been sent
from the postpartum unit due to a staffing shortage for the shift. Which of the following client
assignments should the nurse delegate to the LPN?
Answer: A client who is postoperative following a bowel resection with a NG tube set to
continuous suction
A nurse is caring for a 1 day old newborn who has jaundice and is receiving phototherapy. Which
of the following actions should the nurse take?
Answer: Ensure that the newborn wears a diaper
A nurse is providing discharge teaching to a client who has a new prescription for phenelzine.
The nurse should instruct the client that is safe to eat which of the following foods while taking
this medication?
Answer: Whole grain bread
A nurse in a PACU is caring for a client who is postoperative following a knee arthroplasty using
general anaesthesia. Which of the following findings should the nurse report to the provider
immediately?
Answer: Nasal flaring is present with inspiratory stridor
A nurse is planning care for a group of clients. Which of the following methods should the nurse
use to manage time effectively?
Answer: Gather supplies prior to completing a dressing change
A nurse is assessing a client who is receiving peritoneal dialysis for manifestation for peritonitis.
Which of the following findings should the nurse identify as the first indication of peritonitis?
Answer: Abdominal pain
A charge nurse is supervision the care of four clients. For which of the following occurrences
should the nurse complete an incident report?
Answer: A nurse forgets to document the administration of a medication
A nurse is caring for a client who is comatose and has advance directives that indicate the client
does not want life sustaining measures. The clients family wants the client to have life sustaining
measures. Which of the following actions should the nurse take?
Answer: Arrange for an ethics committee meeting to address the family’s concerns
A nurse is preparing to administer a NG tube feeding to a school age child. Which of the
following actions should the nurse plan to take?
Answer: Measure the tubing form the nose to the distal port
A nurse is reviewing the lab report of a client who has been receiving lithium carbonate for the
past 12 months. The nurse notes a lithium level of 0.8. which of the following orders from the
provider should the nurse expect?
Answer: Administer the medication
A nurse is a mental health facility is airing for a child who is experiencing a panic level of
anxiety. Which of the following actions should the nurse take?
Answer: Encourage the client to take about his feelings
A nurse is teaching a group of newly licensed nurses about client advocacy. Which of the
following statements by a newly licensed nurse indicates an understandings of the teaching?
Answer: I will interfere if there is a conflict between a client and his provider
A nurse in a surgical clinical is teaching to a client who is scheduled for a modified radical
mastectomy. Which of the following statements by the client indicates an understanding of the
teaching?
Answer: I will complete my arm exercises four times daily
A nurse is preparing to perform a dressing change on a preschooler. Which of the following
actions should the nurse to prepare the child for the procedure?
Answer: Explain in simple terms how the procedure will affect the child
A nurse is teaching a client who has a new prescription for oxycodone extended release. Which
of the following instructions should the nurse include?
Answer: Increase daily fibre intake
A Charge nurse is teaching a group of newly licensed nurses about the correct use of restraints.
Which of the following examples should the charge nurse include in the teaching?
Answer: Keeping the side rails of a toddlers crib elevated
A charge nurse is teaching a newly licensed nurse about the facilities computerized
documentation system. Which of the following information should the nurse include?
Answer: Information technology will install a firewall to secure client information
A nurse overhears two assistive personals discussing care for a client while in the elevator..
which of the following actions should the nurse take?
Answer: Report the incident to the ap’s charge nurse
A nurse is assessing a client who is 1 day postoperative following the placement of an ileostomy.
Which of the following findings should the nurse report to the provider?
Answer: The stoma has a purplish hue
A nurse is providing teaching to a client who has heart failure and a new prescription for
furosemide. Which of the following statements should the nurse make?
Answer: Rise slowly when getting out of bed
A home health nurse is performing a home safety evaluation for an older adult client who uses a
walker. The nurse should identify that which of the following findings indicates proper home
safety?
Answer: The client utilizes a night light in the hallway and bathroom
A nurse is assessing a school age child who has a urinary tract infection. Which of the following
should the nurse expect?
Answer: Enuresis
A nurse is teaching a newly licensed nurse about incident reports. Which of the following
statements by the newly licensed nurse indicates an understandings of the teaching?
Answer: They assist with unit quality improvements
A nurse is caring for a client who has preeclampsia and is receiving magnesium sulphate. The
nurse should identify that which of the following findings is a manifestation of magnesium
toxicity?
Answer: Hyperreflexia
A nurse is preparing to teach the parents of a child who has cystic fibrosis. Which of the
following instructions should the nurse plan to include?
Answer: Provide a diet high in protein and calories
A nurse is admitting a client who has a blood culture positive for MRSA. There are no private
rooms available. The nurse should place the client in a room with which of the following clients?
Answer: A client who has CDIFF
A nurse is caring for a client who is at 11 weeks of gestation. Which of the following
immunization should the nurse recommend?
Answer: Influenza
A nurse is reviewing home recommendations with a client who is postoperative following knee
surgery. Which of the following recommendations should the nurse make?
Answer: Place handrail in the entryway of the house
A nurse is caring for a client who has gestational hypertension and is experiencing toxic effects
due to magnesium sulphate therapy. The nurse should anticipate administering which of the
following medications?
Answer: Calcium gluconate
A nurse is providing teaching about crutch safety to a client. Which of the following client
actions indicates an understanding of the teaching?
Answer: The client keeps her axillae free of pressure
A nurse is caring for a client who is 12 hr postoperative following a TURP. Which of the
following findings should the nurse report to the provider?
Answer: Burgundy coloured urine
A nurse on a mental health unit is caring for a client who is being admitted immediately
following a sexual assault. Which of the following interventions should the nurse include in the
plan of care?
Answer: Limit the number of staff members providing care to the patient
A nurse is assessing an older adult client for social isolation. The nurse should identify that
which of the following statements by the client indicates a risk for social isolation?
Answer: My son moved across the country for a new job
A nurse is caring for a group of clients. Which of the following actions by the nurse demonstrates
client advocacy?
Answer: Assisting a client to obtain a second opinion for a diagnosis
A nurse in an ER is caring for a client who has a closed head injury. Which of the following
actions should the nurse take first?
Answer: Determine the clients Glasgow coma scale score
A nurse is preparing to assist with the lumbar puncture of an infant. The nurse should plan to
place the infant in which of the following positions?
Answer: Flexed side lying
A nurse is caring for a school age child who has sickle cell anaemia and is in Vaso-occlusive
crisis. Which of the following actions should the nurse take?
Answer: Increase oral fluid intake
A nurse is caring for a client who has chronic kidney failure and a serum potassium level of 6.8.
which of the following actions should the nurse take?
Answer: Initiate continuous cardiac monitoring for the client
A nurse is caring for a client who is wearing antiembolic stockings. Which of the following
interventions should the nurse include in the plan of care?
Answer: Determine if the stockings are binding
A nurse in a family practice clinic for idiopathic scoliosis. Which of the following assessments
should the nurse perform as part of this screening?
Answer: Observe for sacral dimpling
A nurse is educating the guardian of a toddler about the behaviours to expect immediately
following discharge. Which of the following statements should the nurse include in the teaching?
Answer: Your child will demand your attention after a period of acting indifferent
A nurse realizes that the wrong medication has been administered to a client. Which of the
following actions should the nurse take first?
Answer: Measure the clients vital signs
A nurse is preparing to assist the provider with a paracentesis for a client who has ascites. Which
of the following actions should the burse plan to take?
Answer: Have the client void prior to the procedure
A nurse is caring for a client who is in the advanced stage of ALS. Which of the following
referral is the nurses priority?
Answer: Speech therapy
A nurse is working in a health department is conducting a health screening for a group of
farmworkers. Which of the following client statement indicates a possible health risk?
Answer: I eat veggies directly from the field where I work
A nurse is caring for a client who received a transfusion of 250 mL of packed RBCs. The nurse
should identify that which of the following findings indicates the client is responding positively
to the transfusion?
Answer: The client’s haemoglobin (Hgb) level increases following the transfusion.
A nurse is caring for a group of client who have chronic pain. Which of the following clients
should the nurse identify as a candidate for OT?
Answer: A client who had painful hands due to degenerative joint disease
A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right
hemisphere stroke. Which of the following interventions should the nurse include in the plan?
Answer: Place the clients left arm on a pillow while he is sitting
A nurse is assessing a client who is postoperative and has a history of pulmonary embolism.
Which of the following findings is the priority for the nurse to report to the provider?
Answer: Dyspnea
A nurse is providing dietary teaching to a client who had CKD. Which of the following
instructions should the nurse include?
Answer: Restrict foods containing phosphorus
A nurse is preparing to obtain a health history from a client who is on bedrest. Which of the
following positions should the nurse take to place the client at ease?
Answer: Sit in a chair next to the bed
A newly licensed nurse is reviewing the role of a nurse in disaster planning, which of the
following is an activity a nurse should engage to assist in disaster preparedness?
Answer: Participate in community drills and mock events
A nurse is speaking with the partner of a client who is in the early stages of alzheimers disease.
The partner tells the nurse that she is able to manage the clients physical care, but she doesn’t
want to leave him home alone while she travels for work. Which of the following referrals
should the nurse make?
Answer: Respite care
A nurse manager is reviewing documentation with a newly licensed nurse. Which of the
following notations by the new nurse indicates an understanding of the teaching?
Answer: Dressing changed qd
A charge nurse is providing an in-service to staff nurses about organ donation. The charge nurse
should instruct the staff nurses to continue life support for the donor client in order to retrieve
which of the following organs? SATA
Answer: Liver heart kidneys
A nurse is admitting a client who has schizophrenia to the mental health unit. The client states I
have no one who cares. Which of the following responses should the nurse make?
Answer: Tell me about your family
A nurse is an ED is caring for a child who reports being sexually abused by a family member,
which of the following actions should the nurse take?
Answer: Explain to the child what will happen when the abuse is reported
A nurse is providing dietary teaching to a client who has ESKD and a potassium level of 6.
Which of the following is the best food for the nurse to recommend to the client?
Answer: I cup of cubed cantaloupe
Nurse is caring for a client who has increased intracranial pressure following a traumatic brain
injury. Which of the following action should the nurse take? SATA
Answer: Maintain the head of bed at a 30 angle, administer stool softeners, provide a quiet
environment for the client
A nurse in the infection diseases division of the local health department is caring for a client.
Which of the following should the nurse identify should be reported to the health department?
Answer: HPV
A nurse is initiating a prescription for a dopamine continuous IV infusion for a client who has
heart failure. Which of the following actions should the nurse take?
Answer: Titrate the dose to achieve desired effects
A nurse is caring for a client who has a major burn injury. Which of the following is the nurses
priority to prevent wound infections?
Answer: Maintain consistent handwashing by the staff
A nurse is providing discharge teaching for a client who has a new diagnosis of multiple
sclerosis. Which of the following client statements indicates an understanding of the teaching?
Answer: I should participate in aerobic exercise daily
A nurse is reviewing the medication administration record of a client. Which of the following
prescriptions should the nurse clarify?
Answer: Digoxin
A nurse is teaching a newly licensed nurse about postpartum haemorrhage. Which of the
following statements by the newly licensed nurse indicates an understandings of the teaching?
Answer: Inversion of the uterus is the leading cause of postpartum haemorrhage
A nurse is preparing to discharge a client who lives alone and expresses needing help
administering their medications. The nurse should investigate which of the following services
with the client prior to discharge?
Answer: Assisted living
A nurse is providing teaching to the parents of a newborn who is been circumcised. Which of the
following instructions should the nurse include in the teaching?
Answer: Apply petroleum jelly to the glans with diaper changes
A nurse on a paediatric unit is preparing to insert an IV catheter for a 7year old who is
dehydrated. Which of the following actions should the nurse take?
Answer: Tell the client there will be discomfort during the catheter insertion
A nurse is performing gastric lavage for a client who has upper gastrointestinal bleeding. Which
of the following actions should the nurse take?
Answer: Insert a large bore NG tube
A nurse is caring for a client who is at 38 weeks gestation is in active labor. Which of the
following actions should the nurse take?
Answer: Applying a fetal heart rate monitor
A community health nurse is reviewing lab reports for a group of clients. The nurse should
identify that which of the following disorders is on the CDCs nationally notifiable conditions
list?
Answer: Lyme disease
A nurse is assessing an older adult client who had a left sided stroke. Which of the following
findings should the nurse expect?
Answer: Loss of depth perception
A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following
actions should the nurse plan to take?
Answer: Secure the urinary catheter to the client’s thigh
A charge nurse is preparing to lead negotiations among nursing staff due to a conflict about
overtime requirements. Which of the following strategies should the charge nurse use to promote
effective negotiation?
Answer: Attempt to understand both sides of the issue
A nurse is caring for a client whose partner recently died. The nurse sits with the client to provide
comfort. Which of the following ethical principles is the nurse demonstrating?
Answer: Beneficence
A nurse is caring for a client who has respiratory depression from an opioid administration. After
administering naloxone to the client, which of the following findings should the nurse expect?
Answer: Hypoventilation
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: Report the client’s assault to the authorities
A nurse is flushing a client’s intermittent infusion device. The client states “why do you have to
do that if you are not giving me medicine?” Which of the following statements should the nurse
make?
Answer: “This clears blood from the tubing and the catheter”
A nurse is assisting with food selection for a client who follows kosher dietary traditions. Which
of the following food choices should the nurse include on the client’s food tray?
Answer: Scrambled eggs and toast with milk
A nurse is assessing a client who is receiving morphine IV for pain. Which of the following
findings should the nurse report to the provider first?
Answer: BP 80/40
A director of nursing in a rehab facility is planning to measure the quality of care provided.
Which of the following audits should the director plan to use after clients are discharged to
gather about quality of care?
Answer: Outcome audit
A nurse is caring for an infant who has RSV. Which of the following interventions should the
nurse take?
Answer: Administer Palivizumab intravenously
A nurse is preparing to administer ranitidine 50 mg IV over 15 mins to a client. Available is
ranitidine 50 mg in 0.9% sodium chloride solution 100ml. the nurse should set the IV pump to
deliver how many ml/hr?
Answer: 400
A nurse is caring for a client who has preeclampsia and is experiencing a postpartum
hemorrhage. The nurse should expect the provider to prescribe which of the following
medications?
Answer: Oxytocin
A nurse has identified tasks to delegate to a group of Aps after receiving change of shift report.
Answer: • Review the skill level and qualification of each AP
• Communicate appropriate tasks to the Aps with specific expectations
• Monitor progress of task completion with each AP
• Evaluate the AP’s performance of each task
A nurse is assessing a new born 2 hr following birth. Which of the followings finding should the
nurse expect?
Answer: HR 190/min
A nurse is providing teaching to a client who is on glucocorticoid therapy. Which of the
following statements by the client indicates an understanding of the teaching?
Answer: I consistently take my medication between 8 and 9 each evening
A nurse is caring for a client who has depression and reports taking St. Jon’s wart along with
citalopram
Answer: Serotonin syndrome
A nurse is assessing a clients coccyx area for a pressure ulcer. The nurse notes that superficial
subcutaneous fat is visible and tunnelling is present. Which of the following pressure ulcer stages
should the nurse document?
Answer: Stage 3
A nurse on a medical surgical unite is performing medication reconciliation for a newly admitted
client. Which of the following actions should the nurse take?
Answer: Compare the clients list of home medications to the admission prescriptions written for
the client
A nurse is reviewing the medicating administration record of a client who has BPH. The client
asks the nurse about taking saw palmetto. The nurse should instruct the client that which of the
following medications interacts adversely with saw palmetto?
Answer: Clopidogrel
A nurse is providing discharge instructions about newborn safety to a client who is 2 days
postpartum. Which of the following instructions should the nurse include?
Answer: Use a car seat when traveling by airplane
A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations.
Which of the following actions should the nurse take?
Answer: Encourage the client to listen to music
A staff nurse is observing a newly licensed nurse suction a client’s tracheostomy. Which of the
following actions by the newly licensed nurse requires intervention by the staff nurse?
Answer: Applies suction for 15 seconds
A nurse is preparing to perform a sterile wound irrigation and dressing change for a client. Which
of the following actions by the nurse indicated a break in surgical aseptic technique?
Answer: Balancing the bottle on the sterile basin while pouring the liquid
A nurse is caring for a client who has a new prescription for warfarin. When reviewing the
clients current medications, which of the following medications should the nurse identify as
contraindicated for use with warfarin?
Answer: "Aspirin, ibuprofen, ginkgo biloba."
A nurse is caring for a clients who experienced a stroke 4 days ago and has dysphagia. Which of
the following actions should the nurse take to assist the client during meals?
Answer: Place small bites of food in the unaffected side of the client’ mouth
A nurse is caring for a client who has major depressive disorder. The client tells the nurse “no
one cares about me, I’m completely alone”
Answer: The nurse should respond empathetically, "I’m really sorry to hear that you feel this
way; I’m here to listen and support you."
