ATI Comprehensive Predictor Exam With Answers-301 Solved Questions

ATI COMPREHENSIVE ATI A
1. A nurse in a LTC facility notices a client who has Alzheimer’s disease standing at the exit door
at the end of the hallway. The client appears to be anxious & agitated. What action should the
nurse take?
Answer: Escort the client to a quiet area on the nursing unit.
Explanation:
A client c Alzheimer experiences chronic confusion. Guiding the client to a quiet, familiar area
will help decrease agitation. They will be unable to follow instructions/commands.
2. A nurse is assisting with the plan of care for a client who has a continent urinary diversion.
Which intervention should the nurse plan to implement to facilitate urinary elimination?
Answer: Use intermittent urinary catheterization for the client at regular intervals.
Explanation:
A continent urinary diversion contains valves that prevent urine from exiting the pouch;
therefore, the nurse should plan to insert a urinary catheter at regular intervals to drain urine from
the client’s pouch.
3. A nurse is assisting with an education program about car restraint safety for a group of parents.
Which statement by the parent indicates an understanding of the instructions?
Answer: “My 12YO child should place the shoulder-lap seatbelt low across his hips.”
Explanation:
When a child is old enough to only use a shoulder-lap seatbelt, he should place it low across his
hips rather than over the abdomen to reduce risk for injury during motor vehicle crash.
4. A nurse is reinforcing teaching about strategies to promote eating with a client who has COPD.
Which instructions should the nurse include in the teaching?
Answer: Drink high-protein and high-calorie nutritional supplements.
Explanation:

The nurse should instruct the client to drink high-protein and high-calorie nutritional
supplements to maintain respiratory muscle function. COPD causes respiratory stress that leads
to hypermetabolism and wasting of the client’s muscle mass.
5. When removing PPE after direct care for a client who requires airborne & contact precautions,
which PPE is removed first?
Answer: Gloves
Explanation:
The greatest risk is contamination from pathogens that might be present on the PPE; therefore,
the priority action for the AP is to remove the gloves, which are considered the most
contaminated.
6. A nurse is inspecting the skin of a newborn. Which finding should the nurse report to the PCP?
Answer: Generalized Petechiae
Explanation:
Petechiae are an expected finding over the presenting part of the newborn, such as on the
forehead in a brow presentation, & also anywhere on the head of infants who had a nuchal cord,
w/c is an umbilical cord around the neck. However, petechiae all over the newborn’s body can
indicate infection or decreased platelet count and should be reported to the provider.
7. A nurse is contributing to a teaching plan for a group of male adolescents about the A/E of
anabolic steroid use. Which manifestations should the nurse include?
Answer: Reduced height potential
Explanation:
Use of anabolic steroids in adolescence can lead to premature epiphyseal closure, thus reducing
full height potential. A/E includes: Liver disorders, hyperlipidemia, breast enlargement, acne,
and edema.
8. A nurse is reinforcing teaching with an older adult client who has severe L-sided HF. Which
statement should the nurse make?
Answer: Rest for 15 minutes between activities.

Explanation:
The nurse should instruct to increase his activity gradually & to rest for a period of 15 min if he
becomes tired. Clients who have HF should balance activity c rest to reduce cardiac workload.
9. A nurse in a LTC facility is documenting the care of an older adult client. Which information
should be included in weekly nursing care summary?
Answer: Hydration Status
Explanation:
Older adult client are at risk for dehydration. Therefore, the nurse should be vigilant about
monitoring the client’s hydration status & include this information in the weekly nursing care
summary.
10. A nurse is caring for a client who has a head injury. Using the Glasgow Coma Scale to collect
data, the nurse should obtain which information?
Answer: Motor Response
Explanation:
The nurse should collect data about the client’s motor response & assign the response a score of
1-6, according to the Glasgow Coma Scale.
11. A home health nurse is reinforcing teaching with a client about the use of elastic stockings to
decrease peripheral edema. Which instruction should the nurse include?
Answer: Apply the stocking in the morning.
Explanation:
The nurse should instruct the client to apply the elastic stocking in the morning and remove them
at the end of the day before bedtime.
12. A nurse is obtaining health hx from a client who is scheduled to undergo cardiac
catheterization in 2 days. Which questions is the priority for the nurse to ask?
Answer: “Do you know if you’re allergic to iodine?”
Explanation:
The greatest risk to the client is an allergic reaction to the contrast agent, which contains iodine.

13. A nurse is planning to administer nystatin oral suspension to a client who has oral
candidiasis. Which instructions should the nurse give?
Answer: “Hold the medication in your mouth for several minutes prior to swallowing”
Explanation:
The client should swish & hold the liquid in the mouth for at least 2 min to facilitate contact of
the medication with the organism. The client should then swallow or spit out the medication.
14. A nurse is preparing to care for the assigned clients on her upcoming shift. Which time
management strategies should the nurse plan to use?
Answer: Prepare a priority list of client needs for the shift.
Explanation:
The nurse should prepare a client priority-to-do list, which could include administering timecritical medications. This will allow the nurse to determine which clients should receive care
first.
15. After witnessing the consent, what action should the nurse take next?
Answer: Ask client what he understands about the procedure.
16. Which task should the nurse assign to an AP for a pt 2 days post-op ff Total knee
arthroplasty?
Answer: Reapply antibiotic stockings to the client ff a shower.
17. A nurse is reinforcing teaching with a client who is receiving radiation therapy for cancer of
the larynx. Which statement made by the client indicates understanding of the teaching?
Answer: “I will wear a soft scarf around my neck when I am outside”
Explanation:
Wash it with plain water without soap. NO heat source therapy. Only use electric razor, if
necessary, for shaving.

18. A nurse is using FLACC scale to determine the level of pain for an 11-months-old infant who
sis port-op. Which factor should the nurse consider when using this pain scale?
Answer: Level Of Activity
Explanation:
The nurse should consider the infants level of activity when using FLACC pain scale. The
FLACC is determined by five categories of behavior: Facial Expression, Leg Movement,
Activity, and Consolability.
19. A nurse is collecting data from a 5YO child at a well-child visit. Parent reports that the child
is having frequent nightmares. Which statements by the parents indicates to the nurse that the
child Is experiencing sleep terrors rather than nightmares?
Answer: “My child goes back to sleep right away.”
Explanation:
The nurse should realize that going back to sleep quickly is an indication of sleep terrors, rather
than nightmares. A child who is experiencing nightmare has difficulty returning to sleep because
of continued fear.
20. A nurse is assisting with the care of a school-age child immediately ff surgery. The child
weighs 21.8 kg (48 lb) & has a chest tube applied to suction. Which finding should the nurse
report to PCP?
Answer: 250 mL of sanguineous drainage over the last 3 hr
Explanation:
More than 3 mL/kg/hr of sanguineous drainage occurs for more than 2-3 consecutive hr ff
surgery. It indicates active haemorrhaging.
21. A nurse is reinforcing teaching with an older adult client who has osteoarthritis. Which
instructions should the nurse include?
Answer: Apply capsaicin cream 4x/day
Explanation:
Apply it topically to provide warmth & relieve joint pain.

22. A nurse is reinforcing teaching about managing manifestation of anxiety with a client who
has generalized anxiety disorder. Which information should the nurse include?
Answer: Say the word “STOP” when upsetting thoughts occur.
23. A nurse in a LTC facility is collecting data form a client who has been receiving betaxolol to
treat glaucoma. Which findings is an A/E if this medication?
Answer: Bradycardia
Explanation:
Betaxolol is a beta blocker that can produce systemic effects, including bradycardia.
24. A nurse in an outpatient surgery center is reinforcing discharge teaching with a client ff a
lithotripsy for uric acid stones. Which instructions should the nurse plan to include?
Answer: Strain the urine to collect stone fragments.
25. A nurse in a provider’s office is reinforcing teaching with a client who is to follow a 2,000
mg sodium-restricted diet. Which client food selections indicates understanding of the teaching?
Answer: Canned Peaches.
26. A nurse is preparing to perform a bladder scan for a client. Which action should the nurse
take?
Answer: Tell the client she should not experience any discomfort.
27. A nurse is contributing to the plan of care for a client who has a prescription for ROM
exercises of the shoulder. Which exercise should the nurse recommend promoting shoulder
hyperextension?
Answer: Move her arm behind her body with her elbow straight.
28. A nurse is collecting data from an older adult client who has a gastric ulcer. Which finding
should the nurse identify as a complication to report to the provider?
Answer: Hematemesis

29. A nurse is discussing the use of epidural analgesia with a newly licensed nurse. Which
statement by the newly licensed nurse indicates understanding of this method of pain control?
Answer: “I should report leaking at the insertion site to the anaesthesiologist”
30. A nurse is contributing to the plan of care for a client who is receiving continuous bladder
irrigation immediately ff a transurethral resection of the prostate (TURP). Which of the ff
interventions should the nurse include?
Answer: Maintain a drainage flow rate to keep the urine diluted to a reddish-pink colour.
31. A nurse is caring for a client who is scheduled for a mastectomy the ff day. The client is
tearful & tells the nurse that she is not ready to have this procedure done at this time. What
response should the nurse give?
Answer: “Would you like for me to talk to the surgeon with you?”
32. A nurse is collecting data from a school-age child who has hypoglycaemia. What is the
manifestation to expect?
Answer: Sweating
33. A nurse is assisting with a community education program for parents of preschoolers about
recommended activities to promote physical development. Which of the ff statement should the
nurse make?
Answer: “You should provide unorganized play activities for your child each day.”
34. A nurse is collecting data from a client who has chronic pancreatitis and is receiving
pancrelipase. Which findings indicates the client is experiencing a therapeutic response to this
medication?
Answer: Report of a decrease in the number of stools.
Explanation:
Pancrelipase is administered as a replacement therapy for a deficiency in pancreatic enzymes,
which results in steatorrhea, or fatty stools.

35. A nurse is caring for a client who is 12-hour post-op ff total knee arthroplasty. What action
should the nurse take?
Answer: Place an abduction wedge between the client’s legs when he is in bed.
36. A nurse is reinforcing teaching regarding puberty with a group of prepubescent female
clients. Which information should the nurse include in the teaching?
Answer: “You will gain weight before you start to get taller.”
37. Why are oral contraceptives contraindicated for patients with coronary artery disease (CAD)?
Answer: No Oral Contraceptives For CAD
38. A nurse is caring for a client who is at 34 weeks gestation and has mild preeclampsia. Which
finding indicates a progression from mild to severe preeclampsia?
Answer: Client reports of blurred vision.
39. A nurse is reinforcing teaching with a client who has asthma & has a prescription of
theophylline. What statement should the nurse make?
Answer: Discontinue drinking caffeinated beverages.
40. A/E of metronidazole
Answer: Reddish-brown urine.
41. A home health nurse is collecting data from an older adult client who has generalized anxiety
disorder. The client lives at home with her partner & sibling. Which responses by the client’s
partner is the priority for the nurse to address?
Answer: “Her prescription isn’t generic, so we can’t afford it anymore.”
42. Patient having difficulty using eating utensils.
Answer: Refer patient to OT.
43. What should parents do if their child has ingested a full bottle of acetaminophen?

Answer: instruct parents to take the child to the ER
44. A client requesting information from a nurse about creating a health care proxy. Which
statement should the nurse make?
Answer: “The person you appoint will make health care decisions for you if you cannot do so
yourself.”
45. Where is the preferred site for venipuncture?
Answer: antecubital fossa
46. What should the nurse do if a patient develops edema above the catheter insertion site during
an infusion?
Answer: The nurse should stop the infusion if the patient is having edema above the catheter
insertion site.
47. A nurse is contributing to the plan of care for a client who has pneumonia. Which entries
should the nurse include in the plan?
Answer: “Client prefers bathing in the evening.”
48. Strategies to teach parents about pediculosis capitis (Head lice) management:
Answer: Store child clothing in a separate cubicle when at school. Boil brushed and combs in
water for 10 min. Dry bed linens & clothing in a hot dryer for at least 20 min.
49. Caring for a client who has GTube. What actions should the nurse take?
Answer: Flush the tube with 50-60 mL of warm water if the tube becomes clogged.
50. Caring for client who is 4 hr post-op ff GI surgery & NG is placed for decompression. Which
action should the nurse take?
Answer: Keep the plugged tube above the level of the stomach when the client is ambulating.

51. Reinforcing teaching with a client who is scheduled for an exercise electrocardiography
(ECG) stress test. What instruction to give?
Answer: Recommend the client wear comfortable shoes during the test.
Explanation:
Informed consent must be signed, Instruct client to eat 2-3 hr before test and then remain NPO to
prevent GI upset during test.
52. What should the nurse do for a client who practices Orthodox Judaism and has a terminal
illness regarding post-death care?
Answer: The nurse should assure the client that a family member or designated person will stay
with the body after death, in accordance with Orthodox Jewish customs.
53. A client who has pneumonia and is currently receiving oral antibiotic may be discharged to
have more rooms for new admission patient.
Answer: Yes, a client with pneumonia who is stable and responding well to oral antibiotics may
be considered for discharge, provided they meet discharge criteria, such as improved symptoms
and the ability to continue treatment and self-care at home. This can help free up hospital rooms
for new admissions.
54. Avoid Ibuprofen when taking “PRIL” medications.
Answer: Ibuprofen should be avoided when taking "PRIL" medications (angiotensin-converting
enzyme inhibitors, such as enalapril, lisinopril) because combining the two can increase the risk
of kidney damage. Ibuprofen may reduce the effectiveness of the "PRIL" medications and
increase the likelihood of kidney-related side effects, especially in individuals with pre-existing
kidney problems.
55. A nurse observes a client in labor. What interventions should the nurse recommend?
Answer: Squatting using a birth ball, Counter pressure to the sacral area, & leaning forward
while kneeling.

56. Sitting and leaning forward using both hands for support is an expected finding for a 7-month
old infant.
Answer: Yes, sitting and leaning forward using both hands for support is an expected
developmental milestone for a 7-month-old infant.
57. Type 1 DM, patient indicates understanding of patient teaching when he/she states that, “I
will dispose of my needles in a plastic laundry detergent container”.
Answer: It is puncture-proof!
58. What should the nurse do if a client is having difficulty sleeping?
Answer: Offer client a whole grain cracker before bedtime if they are having difficulty sleeping.
59. What is the relationship between red meat and iron?
Answer: Red meat is a good source of heme iron, which is the type of iron that is more easily
absorbed by the body. Consuming red meat can help prevent iron deficiency and support healthy
red blood cell production.
60. What is the relationship between peanut butter and protein?
Answer: Peanut butter is a good source of plant-based protein, providing essential amino acids
that help in muscle repair and growth. It is often included in diets to support protein intake.
61. What is an expected clinical manifestation for a client with a hip fracture?
Answer: External rotation of the affected leg is an expected clinical manifestation in a client
with a hip fracture. This occurs due to muscle spasms and misalignment of the hip joint after the
fracture.
62. What action should a nurse take prior to performing an immunization on a preschooler?
Answer: The nurse should say, "Let’s give the medication to your doll first," to help familiarize
the preschooler with the process and reduce anxiety, making the experience less intimidating.
63. What type of stool should be expected 24 hours after the birth of an infant?

Answer: Dark green and viscous is the stool to expect 24 hrs after birth of an infant.
64. What is a common adverse effect of atorvastatin?
Answer: Muscle Pain
65. What activity could be suggested for a patient with bipolar disorder in a manic phase?
Answer: Suggest walking outside with a staff member to a patient with bipolar disorder & in a
manic phase.
66. How can gonorrhoea affect fertility, and what should be included in STI patient teaching?
Answer: Gonorrhoea can cause infertility if untreated, especially in women, due to
complications like pelvic inflammatory disease. Patient teaching should include the importance
of early treatment, regular screenings, and safe sex practices.
67. What is an indication of physical neglect when collecting data from a toddler?
Answer: Physical neglect indication when collecting a from a toddler is when “the toddler is
inadequately dressed for the weather”
68. Overdose digoxin?
Answer: Check VS
69. Anorexia Nervosa care plan?
Answer: Record I&O
70. What should be included in documentation when a client is NPO before a procedure?
Answer: Documenting client care in the medical record, entries to include would be “Client
remains NPO until X-Ray procedure is complete”
71. To initiate Babinski reflex?
Answer: Stroke the sole of the infant’s foot upward & toward the great toe.

72. What should be done if an ECG result shows a PR interval of 0.24 seconds?
Answer: The ECG result with a PR interval of 0.24 seconds should be reported, as it indicates a
prolonged PR interval, which may suggest a first-degree heart block. Further assessment and
clinical correlation are needed.
73. When patient report of nuchal rigidity, H/A, along with fever & chills. The nurse should
anticipate the MD to order what diagnostic tests?
Answer: Cerebrospinal fluid analysis
Explanation:
The client findings are consistent with bacterial meningitis. A lumbar puncture should be
performed to obtain cerebrospinal fluid to confirm the diagnosis.
74. Post-Op Lumbar puncture:
Answer: Instruct patient to increase fluid intake.
75. When should the client take montelukast?
Answer: The client must take montelukast once daily at bedtime.
76. What should be done to assist with possible adverse effects when taking phenytoin?
Answer: Perform daily gum massage when taking phenytoin as a measure to assist with the
possible A/E.
77. Lung sound:
Answer: Wheezes
78. Morphine A/E:
Answer: Respiratory Rate of 10/min
79. What should be done if there is an unexpected finding in a client's care?
Answer: The unexpected finding should be documented as a variance in the medical record to
accurately reflect the deviation from the expected outcomes or care plan.

80. What does a pH of 7.5 indicate in a patient on mechanical ventilation?
Answer: pH 7.5 is a complication of mechanical ventilation
81. What should be done after the recent confirmation of pregnancies?
Answer: After the recent confirmation of pregnancies, appropriate prenatal care should be
initiated, including scheduling follow-up appointments, lab tests, and providing education on
healthy pregnancy practices.
82. What nutritional benefit does spaghetti with red meat sauce provide?
Answer: Spaghetti with red meat sauce provides a good source of carbohydrates from the pasta
and protein and iron from the red meat, contributing to energy and muscle health.
83. What does a urine specific gravity of 1.002 indicate for a patient with diabetes insipidus
(DI)?
Answer: A urine specific gravity of 1.002 in a patient with diabetes insipidus indicates very
dilute urine, which is characteristic of DI, as the kidneys are unable to concentrate urine due to a
lack of antidiuretic hormone (ADH).
ATI comprehensive:
1. 4hr postpartum, boggy uterus with heavy lochia. Which of the following actions should the
nurse take?
Answer: Massage the uterus to expel clots
Explanation:
ABC approach, priority is to massage uterus to expel clots and increase uterine firmness,
resulting in decreased bleeding
2. Deficit in Cranial nerve 2: results in visual impairment and lead to falls
Answer: clear objects from the walking area

3. indicate the progression of labor and are a benign finding
Answer: nurse should continue to monitor FHR
4. What should be reviewed in a patient with potential respiratory or metabolic issues?
Answer: Review ABGs
5. A nurse is interviewing a client who has just lost her home due to a natural disaster. After
ensuring the client's safety, which of the following actions should the nurse take first?
Answer: • Determine the client's perception of the personal impact of the crisis
• First thing in the nursing process is assessment so assess client’s feelings and understanding of
the natural disaster and its personal impact
6. An assistive personnel (AP) and a nurse are turning a client on to her right side. Which of the
following actions by the AP requires the nurse to intervene?
Answer: Places a pillow under the client's right arm
7. A nurse in a community centre is providing an educational session to a group of women about
ovarian cancer. For which of the following manifestations should the nurse instruct the women to
contact their providers?
Answer: • Abd bloating
• The nurse should include the presence of abdominal bloating as an early indication of ovarian
cancer as well as other manifestations which include an increase in abdominal girth, pelvic or
abdominal pain, early satiety, and urinary frequency or urgency.
8. Hypokalemia
Answer: signs and symptoms: muscle weakness and decreased deep tendon reflexes
9. Hypocalcemia
Answer: numbness and tingling of the extremities and around the mouth
10. Car safety, d/c teaching

Answer: • secure the retainer clip at the level of your baby’s armpits
• The nurse should instruct the client to secure the retainer clip at the level of the newborn's
axillae. The bones of the rib cage and sternum provide protection to underlying organs in the
event of a collision. Placing the clip on the abdomen increases the risk for injury to internal
organs.
11. Nurse in ED is admitting a client who has cardiac tamponade, which assessment finding
should the nurse expect?
Answer: • pulsus paradoxus
• The nurse should identify pulsus paradoxus, a finding in which the systolic BP is 10 mm Hg or
greater on expiration than inspiration, as an expected finding of cardiac tamponade, along with
jugular vein distention, bradycardia, and hypotension.
12. Allowable foods for a client who has a hx of uric-acid based urinary calculi formation. Which
of the following foods should the nurse recommend that the client include in his diet?
Answer: • Citrus fruits such as oranges
• Avoid animal-based proteins and alcohol
13. A nurse is caring for a client who has rheumatoid arthritis and has moderate to severe pain in
multiple joints. Which of the following actions should the nurse take to provide comfort to this
client?
Answer: • Allow for frequent rest periods throughout the day
• To maintain muscle strength, joint function and ROM
• Warm shower instead of warm TUB baths
14. first trimester with an acupressure on wrist, indicates that this therapy is having desired
effects?
Answer: • I have not vomited for the past two weeks
• Using an acupressure band on the wrists is a type of complementary and alternative therapy
that applies pressure to a specific part of the body the client can use to alleviate nausea and
vomiting.

15. Risk of development of a pressure ulcer?
Answer: Recent weight loss
16. 4hr post op following a total vaginal hysterectomy, actions to take first?
Answer: • Measure client’s VS
• The first action the nurse should take when using the nursing process is to assess the client. The
nurse should measure the client's vital signs to assess for respiratory depression and hypotension
resulting from anaesthesia.
17. A nurse in an emergency department is reviewing the prescriptions of an older adult client
who has type 1 DM. reports of severe ankle pain after falling from a steps tool at home. Which
order should the nurse verify with the provider?
Answer: • Apply a cold pack to the edematous area on the client’s ankle for 30mins every other
hour
• The nurse should verify a prescription for a cold pack because type 1 diabetes mellitus is a
contraindication 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.
18. Discharge teaching for a client who has colorectal cancer and is post op following a new
colostomy
Answer: Arrange for a referral to social services is correct. Arranging for a referral to social
services is appropriate for a client who faces challenges with self-care, as well as with paying for
medical equipment and supplies.
Initiate a consult with an enterostomal therapist is correct. Initiating a consult with an
enterostomal therapist can assist the client in learning to care for the colostomy.
Provide the client with information about the American Cancer Society is correct. The
client can learn about helpful resources from the American Cancer Society.
Postpone the client's discharge is incorrect. There is no indication that the client should remain
in the facility.

Give the client information about local support groups is correct. A client who has cancer
and a new colostomy can get help with coping from a support group.
19. Alprazolam/Xanax
Answer: • Initiate fall precautions
• Can cause orthostatic hypotension, dizziness, drowsiness and fainting upon arising
20. Celiac dx diet teaching
Answer: Gluten free diet
1. An 8-year-old client is returned to the recovery room after a bronchoscopy. The nurse should
position the client
A. in semi-Fowler's position.
B. prone, with the head turned to the side.
C. with the head of the bed elevated 45° and the neck extended.
D. supine, with the head in the midline position.
Answer: A. in semi-Fowler's position.
2. A 23-year-old man is admitted with a subdural hematoma and cerebral edema after a
motorcycle accident. Which of the following symptoms should the nurse expect to see
INITIALLY?
A. Unequal and dilated pupils.
B. Decerebrate posturing.
C. Grand mal seizures.
D. Decreased level of consciousness.
Answer: D. Decreased level of consciousness.
3. A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the
following findings, if assessed by the nurse, would indicate a possible complication?
A. The client's urine test is positive for glucose and acetone.
B. The client has 1+ pedal edema in both feet at the end of the day.

C. The client complains of an increase in vaginal discharge.
D. The client says she feels pressure against her diaphragm when the baby moves.
Answer: D. The client says she feels pressure against her diaphragm when the baby moves.
4. A 38-year-old woman is returned to her room after a subtotal thyroidectomy for treatment of
hyperthyroidism. Which of the following, if found by the nurse at the patient's bedside, is
nonessential?
A. Potassium chloride for IV administration.
B. Calcium gluconate for IV administration.
C. Tracheostomy set-up.
D. Suction equipment.
Answer: D. Suction equipment.
5. A 59-year-old woman with bipolar disorder is receiving haloperidol (Haldol) 2 mg PO tid. She
tells the nurse, "Milk is coming out of my breasts." Which of the following responses by the
nurse is BEST?
A. "You are seeing things that aren't real."
B. "Why don't we go make some fudge."
C. "You are experiencing a side effect of Haldol."
D. "I'll contact your physician to change your medication."
Answer: C. "You are experiencing a side effect of Haldol."
6. A 69-year-old client is undergoing his second exchange of intermittent peritoneal dialysis
(IPD). Which of the following would require an intervention by the nurse?
A. The client complains of pain during the inflow of the dialysate.
B. The client complains of constipation.
C. The dialysate outflow is cloudy.
D. There is blood-tinged fluid around the intra-abdominal catheter
Answer: C. The dialysate outflow is cloudy.
7. The ABC framework identifies, in order, the three basic needs for sustaining life:

Answer: Airway
Breathing
Circulation
8. An adolescent client is ordered to take tetracycline HCL (Achromycin) 250 mg PO bid. Which
of the following instructions should be given to this client by the nurse?
A. "Take the medication on a full stomach, or with a glass of milk."
B. "Wear sunscreen and a hat when outdoors."
C. "Continue taking the medication until you feel better."
D. "Avoid the use of soaps or detergents for two weeks."
Answer: B. "Wear sunscreen and a hat when outdoors."
9. Adverse effect of Verapamil
Answer: Avoid grapefruit juice
10. Adverse effects of ferrous sulphate
Answer: constipation; upset stomach; black or dark-coloured stools; or. temporary staining of
the teeth.
11. After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client
becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of
the following nursing interventions would be MOST appropriate?
A. Irrigate the nasogastric tube with distilled water.
B. Aspirate the gastric contents with a syringe.
C. Administer an antiemetic medicine.
D. Insert a new nasogastric tube.
Answer: B. Aspirate the gastric contents with a syringe.
12. After a client develops left-sided hemiparesis from a cerebral vascular accident (CVA), there
is a decrease in muscle tone. Which of the following nursing diagnoses would be a priority to
include in his care plan?

A. Alteration in mobility related to paralysis.
B. Alteration in skin integrity related to decrease in tissue oxygenation.
C. Alteration in skin integrity related to immobility.
D. Alteration in communication related to decrease in thought processes
Answer: B. Alteration in skin integrity related to decrease in tissue oxygenation.
13. After sustaining a closed head injury and numerous lacerations and abrasions to the face and
neck, a five-year-old child is admitted to the emergency room. The client is unconscious and has
minimal response to noxious stimuli. Which of the following assessments, if observed by the
nurse three hours after admission, should be reported to the physician?
A. The client has slight edema of the eyelids.
B. There is clear fluid draining from the client's right ear.
C. There is some bleeding from the child's lacerations.
D. The client withdraws in response to painful stimuli
Answer: B. There is clear fluid draining from the client's right ear.
14. After teaching a group of students about the various organs of the upper gastrointestinal tract
and possible disorders, the instructor determines that the teaching was successful when the
students identify which of the following structures as possibly being affected?
A. Large intestine
B. Ileum
C. Stomach
D. Liver
Answer: C. Stomach
15. Alcohol Use Manifestations of Withdrawal
Answer: Body burns 0.5 oz of alcohol per hour
Withdrawal appears within 4-12 hours
Irritability + Tremors + Anxiety
Nausea + Vomiting + HA Diaphoresis
Sleep Disturbances

TACHYCARDIA + HTN
Use Benzodiazepines = tx
Diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide (Librium)
16. alcohol withdrawal
heroin withdrawal
nicotine withdrawal
alcohol abstinence
opioid over dose
Answer: chlordiazeproxide( Librium) methadone( dolophine) bupropion ( wellbutrin) disulfiram
( antabuse) naloxone (narcan)
17. At what age does bone loss begin with osteoporotis what are normal Calcium levels?
Answer: at age 35 (women) 8.6-10 mg/dL
18. Baclofen (Lioresal) therapeutic outcome
Answer: Decrease the frequency and severity of muscle spasms (MS).
19. Bladder retraining for the treatment of urge incontinence
Answer: • Use timed voiding’s to increase intervals between voiding’s/decrease voiding
frequency.
• Perform pelvic floor (Kegel) exercises.
• Perform relaxation techniques.
• Offer undergarments while the client is retraining.
• Teach the client not to ignore the urge to void.
• Provide positive reinforcement as client maintains continence.
• Eliminate or decrease caffeine drinks.
• Take diuretics in the morning.
20. Bowel elimination how to get a specimen collection

Answer: Collect stool specimens for serial fecal occult blood (guaiac) testing 3 times from 3
different defecations. Stool samples should come from fresh stools that are not contaminated
with water or urine.
21. Case Management nursing involves
Answer: Decreasing cost by improving client outcomes
Providing education to optimize health participation
Advocating for services + client's rights
22. A charge nurse is discussing the responsibility of nurses caring for clients who have C.
difficile. Which of the following information should the nurse include in the teaching?
A. Assign the client to a room with a negative air-flow system
B. Use alcohol-based hand sanitizer when leaving the clients room
C. clean contaminated surfaces in the clients room with a phenol solution
D. have family members wear a gown and gloves when visiting
Answer: D. have family members wear a gown and gloves when visiting
23. A client diagnosed with dementia wanders the halls of the locked nursing unit during the day.
To ensure the client's safety while walking in the halls, the nurse should do which of the
following?
A. Administer PRN haloperidol (Haldol) to decrease the need to walk.
B. Assess the client's gait for steadiness.
C. Restrain the client in a geriatric chair.
D. Administer PRN lorazepam (Ativan) to provide sedation
Answer: B. Assess the client's gait for steadiness.
24. A client has a history of oliguria, hypertension, and peripheral edema. Current lab values are:
BUN -25, K+ -4.0 mEq/L. Which nutrient should be restricted in the client's diet?
A. Protein.
B. Fats.
C. Carbohydrates.

D. Magnesium.
Answer: A. Protein.
25. a client has a new prescription for spironilactone ( aldactone ) which of the following
laboratory value should the nurse recognized as a reason to withhold the morning dose of the
medication and notify the provider:
Answer: serum potassium 5.2
26. a client has prescription for valproic ( Depakote) which of the following laboratory value
should the nurse anticipate monitor for the client taking this medication
Answer: thrombocytes, amylase count and liver function test
27. A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the
nurse would expect to find rebound tenderness at which location?
A. Left lower quadrant
B. Left upper quadrant
C. Right upper quadrant
D. Right lower quadrant
Answer: D. Right lower quadrant
28. A client is being discharged with sublingual nitro-glycerine (Nitrostat ). The client should be
cautioned by the nurse to
A. take the medication five minutes after the pain has started.
B. stop taking the medication if a stinging sensation is absent.
C. take the medication on an empty stomach.
D. avoid abrupt changes in posture.
Answer: D. avoid abrupt changes in posture.
29. The client is exhibiting symptoms of myxedema. The nursing assessment should reveal
A. increased pulse rate.
B. decreased temperature.

C. fine tremors.
D. increased radioactive iodine uptake level.
Answer: B. decreased temperature.
30. A client is given morphine 6 mg IV push for postoperative pain. Following administration of
this drug, the nurse observes the following: pulse 68, respirations 8, BP 100/68, client sleeping
quietly. Which of the following nursing actions is MOST appropriate?
A. Allow the client to sleep undisturbed.
B. Administer oxygen via facemask or nasal prongs.
C. Administer naloxone (Narcan).
D. Place epinephrine 1:1,000 at the bedside
Answer: C. Administer naloxone (Narcan).
31. A client is receiving total parenteral nutrition (TPN). To determine the client's tolerance of
this treatment, the nurse should assess for which of the following?
A. A significant increase in pulse rate.
B. A decrease in diastolic blood pressure.
C. Temperature in excess of 98.6°F (37°C).
D. Urine output of at least 30 cc per hour
Answer: D. Urine output of at least 30 cc per hour
32. A client is scheduled for a left lower lobectomy. The physician has ordered diazepam
(Valium) 2 mg IM for anxiety. The nurse would determine that the medication is appropriate if
the client displays which of the following symptoms?
A. Agitation and decreased level of consciousness.
B. Lethargy and decreased respiratory rate.
C. Restlessness and increased heart rate.
D. Hostility and increased blood pressure
Answer: C. Restlessness and increased heart rate.

33. A client returns to his room following a myelogram. The nursing care plan should include
which of the following?
A. Encourage oral fluid intake.
B. Maintain the prone position for 12 hours.
C. Encourage the client to ambulate after the procedure.
D. Evaluate the client's distal pulses on the affected side.
Answer: A. Encourage oral fluid intake.
34. a client should receive a dose of flumazenil ( romazicon) to treat symptoms of
Answer: benzodiazepine overdose
35. a client who has parkinson's disease is prescribed levodopa/carbidopa ( sinemet) and
pramipexole ( Mirapex) for which of the following should the nurse monitor this client
Answer: orthostatic hypotension
36. a client who is start taking lithium carbonate month ago tell the nurse she has just begun
taking multiply daily doses of ibuprofen ( motrin) for tension headache. should the client avoid
ibuprofen. why or why not ?: what , if any is the appropriate action for the nurse to take
Answer: NSAIDS such as ibuprofen increase the renal reabsorption of lithium carbonate ,
possibly leading to lithium carbonate toxicity . therefor this client would avoid NSAIDS . the
nurse should notify the provider of client headache and ibuprofen us
37. discrete and applies the letting go of an object or person before the loss as in the case of
terminal illness individuals have the opportunity to greet before the actual loss:
Answer: anticipatory grief
38. During a home visit to an elderly client with mild dementia, the client's daughter reports that
she has one major problem with her mother. She says, "She sleeps most of the day and is up most
of the night. I can't get a decent night's sleep anymore." Which suggestions should the nurse
make to the daughter? Select all that apply.
A. Ask the client's physician for a strong sleep medicine.

B. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime.
C. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the
day.
D. Promote relaxation before bedtime with a warm bath or relaxing music.
E. Have the daughter encourage the use of caffeinated beverages during the day to keep her
mother awake
Answer: B. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime.
C. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the
day.
D. Promote relaxation before bedtime with a warm bath or relaxing music.
39. An elderly client is returned to her room after an open reduction and internal fixation of the
left femoral head after a fracture. It is MOST important for the nursing care plan to include that
the client
A. eat a high-protein, low-residue diet.
B. lie on her unoperated side.
C. exercise her arms and legs.
D. cough and deep breathe.
Answer: D. cough and deep breathe.
40. An extremely agitated client is receiving haloperidol (Haldol) IM every 30 minutes while in
the psychiatric emergency room. The MOST important nursing intervention is to
A. monitor vital signs, especially blood pressure, every 30 minutes.
B. remain at the client's side to provide reassurance.
C. tell the client the name of the medication and its effects.
D. monitor the anticholinergic effects of the medication
Answer: A. monitor vital signs, especially blood pressure, every 30 minutes.
41. Fill in the blank:
1. _______ is used by interdisciplinary team to make health care decisions about clients with
multiple problems.

Answer: collaboration
2. ________, which may take place at team meetings, allows the achievement of results that the
participants would be incapable of accomplishing if working alone
Answer: collaboration
42. A client with a peptic ulcer had a partial gastrectomy and vagotomy (Billroth I). In planning
the discharge teaching, the client should be cautioned by the nurse about which of the following?
A. Sit up for at least 30 minutes after eating.
B. Avoid fluids between meals.
C. Increase the intake of high-carbohydrate foods.
D. Avoid eating large meals that are high in simple sugars and liquids
Answer: D. Avoid eating large meals that are high in simple sugars and liquids
43. A client with newly diagnosed type I diabetes mellitus is being seen by the home health
nurse. The physician orders include: 1,200- calorie ADA diet, 15 units of NPH insulin before
breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse
observes the man performing a blood sugar analysis. The result is 50 mg/dL. The nurse would
expect the client to be
A. confused with cold, clammy skin and a pulse of 110.
B. lethargic with hot, dry skin and rapid, deep respirations.
C. alert and cooperative with a BP of 130/80 and respirations of 12.
D. short of breath, with distended neck veins and a bounding pulse of 96
Answer: A. confused with cold, clammy skin and a pulse of 110.
44. The clinic nurse is performing diet teaching with a 67-year- old client with acute gout. The
nurse should teach the client to limit his intake of
A. red meat and shellfish.
B. cottage cheese and ice cream.
C. fruit juices and milk.
D. fresh fruits and uncooked vegetables

Answer: A. red meat and shellfish.
45. Describe pre-albumin
Answer: this is the best tool for evaluating nutrition. it has a half-life of 2 days which is much
shorter than albumin so it is much more accurate. (albumin's half-life is 2-3 weeks)
46. A four-month-old infant is admitted to the pediatric intensive care unit with a temperature of
105°F (40.5 °C). The infant is irritable, and the nurse observes nuchal rigidity. Which assessment
finding would indicate an increase in intracranial pressure?
A. Positive Babinski.
B. High-pitched cry.
C. Bulging posterior fontanelle.
D. Pinpoint pupils.
Answer: B. High-pitched cry.
47. health promotion (injury prevention-suffocation): infant (birth-1 yr)
Answer: • avoid plastic bags
• keep balloons out of reach
• ensure crib mattress fits snugly
• ensure crib slats are no more than 6 cm (2.4 in) apart -remove crib mobiles and gyms by 4-5
months
• do not use pillows in crib
• place infant on back for sleep
• keep toys with small parts out of reach
• remove drawstrings from jackets and other clothing
48. The home care nurse is instructing a client recently diagnosed with tuberculosis. It is MOST
important for the nurse to include which of the following as a part of the teaching plan?
A. During the first two weeks of treatment, the client should cover his mouth and nose when he
coughs or sneezes.
B. It is necessary for the client to wear a mask at all times to prevent transmission of the disease.

C. The family should support the client to help reduce feeling of low self-esteem and isolation.
D. The client will be required to take prescribed medication for a duration of 6-9 months.
Answer: D. The client will be required to take prescribed medication for a duration of 6-9
months.
49. How should you respond when client wants to discontinue dialysis: "What has changed to
make you decide this?"
Answer: Seek clarification from client to establish mutual understanding while staying
therapeutic
50. How to prevent adverse effects of oxycodone: can cause respiratory depression. What is the
nursing intervention and/or client education ?
Answer: • Monitor vital signs.
• Stop opioids for respiratory rate less than 12/min, and notify the provider.
• Have naloxone and resuscitation equipment available.
• Avoid use of opioids with CNS depressant medications (barbiturates, benzodiazepines,
consumption of alcohol).
51. hypotension is classified with a reading below normal
Answer: systolic < 90 mm Hg; can be a result of fluid depletion, heart failure, or vasodilation
52. Identifying manifestations of transient ischemic attacks
Answer: symptoms r/t affected area. Rapid onset of weakness, numbness, aphasia, visual field
cuts. 1-2 clusters before stroke.
53. If a client develops cor pulmonale (right-sided heart failure), the nurse would expect to
observe
A. increasing respiratory difficulty seen with exertion.
B. cough productive of a large amount of thick, yellow mucus.
C. peripheral edema and anorexia.
D. twitching of extremities

Answer: C. peripheral edema and anorexia.
54. If a patient has anorexia nervosa and works out constantly
Answer: Allow them to work out and continue their regimen
55. includes the group when decisions are made Motivates by supporting star achievements
Communication occurs up and down the chain of command Work output by staff is usually of
good quality-good when cooperation and collaboration is necessary
Answer: Democratic
56. Interaction of diuretics and ACE inhibitors
Answer: excessive reduction in blood pressure and symptomatic hypotension or hyperkalaemia
57. involves difficult progression through the expected stages of the grieving process grief work
is prolonged and manifestations more severe client may develop suicidal ideation, intense
feelings of guilt and lowered self-esteem somatic complaints persist for an extended period of
time
Answer: dysfunctional grief
58. Levothyroxine effects: Used to restore client's metabolic rate Toxic effects
Answer: heat intolerance, Tachycardia, Weight loss, Hypertension
59. Long term effects of NSAIDS (Ibuprofen)
Answer: Gastric Ulcerations, perforations, haemorrhage, hypertension
60. makes decisions of the group motivates by coercion
communication occurs down the chain of command Work output by the staff is usually highgood for crisis situations and bureaucratic settings
Answer: Authoritative

61. makes very few decisions and does little planning motivation is largely the responsibility of
individuals staff members Communication occurs up and down the chain of command and
between group members Work output is low unless an informal leader evolves from the group
the use of any of these styles may be appropriate depending on the situation
Answer: Laissez faire
62. Malnourished COPD patients:
A. Limit liquid intake at meal times
B. Consume foods w/ protein (like eggs)
C. Maintain an upright position (High Fowler's position) to promote ventilation
D. Use milk instead of water when making soup
Answer: B. Consume foods w/ protein (like eggs)
63. Most managers can be categorized as
Answer: authoritative, democratic, and laissez faire
64. Multiple Sclerosis Patient: Mitoxantrone SE's Mitoxantrone IV every 3 months (chemo drug)
Answer: Report Sore Throat (greatest risk for client is severe infection due to myelosuppression
from mitoxantrone)
Vomiting = causes dehydration
Hair Loss = emotional distress
Amenorrhea = emotional distress
65. Musculoskeletal congenital disorders
Answer: Monitor skin for breakdown areas and prevent pressure sores.
66. A nonstress test is scheduled for a client at 34-weeks gestation who developed hypertension,
periorbital edema, and proteinuria. Which of the following nursing actions should be included in
the care plan in order to BEST prepare the client for the diagnostic test?
A. Start an intravenous line for an oxytocin infusion.
B. Obtain a signed consent prior to the procedure.

C. Instruct client to push a button when she feels fetal movement.
D. Attach a spiral electrode to the fetal head.
Answer: C. Instruct client to push a button when she feels fetal movement.
67. The nurse caring for a child in Buck's skin traction will keep the
Answer: Child pulled up in bed
68. A nurse educator is presenting a module on basic first aid for newly licensed home health
nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse
states the client who has heat stroke will have which of the following?
A. Hypotension
B. Bradycardia
C. Clammy skin
D. Bradypnea
Answer: A. Hypotension
69. The nurse in the outpatient clinic teaches a client with a sprained right ankle to walk with a
cane. What behavior, if demonstrated by the client, would indicate that teaching was effective?
A. The client advances the cane 18 inches in front of her foot with each step.
B. The client holds the cane in her left hand.
C. The client advances her right leg, then her left leg, and then the cane.
D. The client holds the cane with her elbow flexed 60°.
Answer: B. The client holds the cane in her left hand.
70. The nurse is assessing a client with a bleeding gastric ulcer. When examining the client's
stool, which of the following characteristics would the nurse be most likely to find?
A. Green colour and texture
B. Black and tarry appearance
C. Clay-like quality
D. Bright red blood in stool
Answer: B. Black and tarry appearance

71. A nurse is caring for a 37-year-old woman with metastatic ovarian cancer admitted for nausea
and vomiting. The physician orders total parenteral nutrition (TPN), a nutritional consult, and
diet recall. Which of the following is the BEST indication that the patient's nutritional status has
improved after 4 days?
A. The patient eats most of the food served to her.
B. The patient has gained 1 pound since admission.
C. The patient's albumin level is 4.0mg/dL.
D. The patient's haemoglobin is 8.5g/dL.
Answer: C. The patient's albumin level is 4.0mg/dL.
72. A nurse is caring for a client following an acute myocardial infarction. The client is
concerned that providing self-care will be difficult due to extreme fatigue. Which of the
following strategies should the nurse implement to promote the client's independence?
A. request an occupational therapy consult to determine the need for assistive devices
B. assign assistive personnel to perform self-care tasks for client
C. instruct the client to focus on gradually resuming self- care tasks
D. ask the client if a family member is available to assist with his care
Answer: C. instruct the client to focus on gradually resuming self- care tasks
73. A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines
that the client has developed phlebitis and removes the IV catheter. Which of the following
actions should the nurse take next?
A. place a warm compress over the IV site
B. record the findings in the client's chart
C. notify the client's primary care provider
D. prepare to insert a new IV catheter
Answer: A. place a warm compress over the IV site

74. A nurse is caring for a client who decides not to have surgery despite significant blockages in
his coronary arteries. The nurse understands that this clients choice is an example of what
principles?
A. Fidelity
B. Autonomy
C. Justice
D. Nonmalificience
Answer: A. Fidelity
75. A nurse is caring for a client who has an NG tube that is to be irrigated every 8 hr. Which of
the following should be used to irrigate the tube in order to maintain fluid and electrolyte
balance?
A. tap water
B. sterile water
C. 0.9% sodium chloride
D. 0.45% sodium chloride
Answer: C. 0.9% sodium chloride
76. A nurse is caring for a client who has a prescription for wound irrigation. Which of the
following actions should the nurse take?
A. wear sterile gloves when removing the old dressing
B. warm the irrigation solution to 40.5C (105F)
C. cleanse the wound from the centre outwards
D. use a 20 mL syringe to irrigate the wound
Answer: C. cleanse the wound from the centre outwards
77. A nurse is caring for a client who has dementia. Which of the following interventions should
the nurse take to minimize the risk for injury for this client?
A. use a bed exit alarm system
B. raise 4 side rails while client is in bed
C. apply one soft wrist restraint

D. dim the lights in the client's room
Answer: A. use a bed exit alarm system
78. A nurse is caring for a client who has tuberculosis. Which of the following actions should the
nurse take? SATA
A. Place the client in a negative pressure room
B. wear gloves when assisting the client with oral care
C. limit each visitor to 2 hr increments
D. wear a surgical mask when providing care
E. Use antimicrobial sanitizer for hand hygiene
Answer: A. Place the client in a negative pressure room
B. wear gloves when assisting the client with oral care
E. Use antimicrobial sanitizer for hand hygiene
79. A nurse is caring for a client who is having difficulty voiding following the removal in an
indwelling urinary catheter. Which of the following interventions should the nurse take?
A. assess for bladder distention after 6 hr
B. encourage the client to use a bed pan in the supine position
C. restrict the clients intake of oral fluids
D. pour warm water over the clients perineum
Answer: D. pour warm water over the clients perineum
80. A nurse is caring for a client who needs a 24-hr urine collection initiated. Which of the
following client statements indicates an understanding of the procedure?
A. "I had a bowel movement, but I was able to save the urine"
B. "I have a specimen in the bathroom from about 30 minutes ago"
C. "I flushed what I urinated at 7 am and have saved the rest since"
D. "I drink a lot, so I will fill up the bottle and complete the test quickly"
Answer: C. "I flushed what I urinated at 7 am and have saved the rest since"

81. a nurse is caring for a client who prescribed daily dose of both digoxin ( llanoxin ) and
furosemide ( Lasix) . the client potassium level 3.2 mEq/L for which of the following medication
interaction is the client at risk
Answer: Toxic level of digoxin
82. A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping
syndrome, the nurse should advise the client to:
A. restrict fluid intake to 1 qt (1,000 ml)/day.
B. drink liquids only between meals.
C. don't drink liquids 2 hours before meals.
D. drink liquids only with meals
Answer: B. drink liquids only between meals.
83. A nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for
this client during the first 24 hours after admission?
A. Skim milk
B. Nothing by mouth
C. Regular diet
D. Clear liquids
Answer: B. Nothing by mouth
84. The nurse is caring for a manic client in the seclusion room, and it is time for lunch. It is
MOST appropriate for the nurse to take which of the following actions?
A. Take the client to the dining room with 1:1 supervision.
B. Inform the client he may go to the dining room when he controls his behavior.
C. Hold the meal until the client is able to come out of seclusion.
D. Serve the meal to the client in the seclusion room.
Answer: D. Serve the meal to the client in the seclusion room.
85. The nurse is caring for an 80-year-old client with Parkinson's disease. Which of the following
nursing goals is MOST realistic and appropriate in planning care for this client?

A. Return the client to usual activities of daily living.
B. Maintain optimal function within the client's limitations.
C. Prepare the client for a peaceful and dignified death.
D. Arrest progression of the disease process in the client.
Answer: B. Maintain optimal function within the client's limitations.
86. A nurse is caring for an older adult client who has a new prescription for digoxin and takes
multiple other medications. Concurrent use of which of the following medications places the
client at risk for digoxin toxicity?
Answer: Verapamil (Calan)
87. The nurse is caring for a patient following an appendectomy. The patient takes a deep breath,
coughs, and then winces in pain. Which of the following statements, if made by the nurse to the
patient, is BEST?
A. "Take three deep breaths, hold your incision, and then cough."
B. "That was good. Do that again and soon it won't hurt as much."
C. "It won't hurt as much if you hold your incision when you cough."
D. "Take another deep breath, hold it, and then cough deeply
Answer: A. "Take three deep breaths, hold your incision, and then cough."
88. The nurse is caring for a young adult admitted to the hospital with a
severe head injury. The nurse should position the patient
A. with his neck in a midline position and the head of the bed elevated 30°.
B. side-lying with his head extended and the bed flat.
C. in high Fowler's position with his head maintained in a neutral position.
D. in semi-Fowler's position with his head turned to the side.
Answer: A. with his neck in a midline position and the head of the bed elevated 30°.
89. The nurse is caring for clients in the skilled nursing facility. Which of the
following clients require the nurse's IMMEDIATE attention?

A. A client admitted for a cerebral vascular accident (CVA) whose prescription for warfarin
(Coumadin) expired two days ago.
B. A client in pain who was receiving morphine in an acute care institution and was transferred
with a prescription for acetaminophen with codeine.
C. A client who has dysuria and foul-smelling, cloudy, dark amber urine.
D. An immunosuppressed client who has not received an influenza immunization
Answer: A. A client admitted for a cerebral vascular accident (CVA) whose prescription for
warfarin (Coumadin) expired two days ago.
90. A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an
AP. Which of the following info should the nurse share with the AP? Select all:
A. the roommate is up independently
B. The client ambulates with his slippers on over his antiembolic stockings
C. The client uses a front wheeled walker when ambulating
D. The client had pain meds 30 minutes ago
E. The client is allergic to codeine
F. the client ate 50 % of his breakfast this morning
Answer: B. The client ambulates with his slippers on over his antiembolic stockings
C. The client uses a front wheeled walker when ambulating
D. The client had pain meds 30 minutes ago
91. A nurse is implementing a plan of care for a client who is at risk for falls. Which of the
following is an appropriate nursing action?
A. implement a regular toileting schedule
B. encourage the client to wear athletic socks when ambulating
C. place all 4 bed rails in the upright position
D. require a family member to remain at the bedside
Answer: A. implement a regular toileting schedule
92. A nurse is instructing a group of nursing students about the responsibilities involved with
organ donation and procurement. When the nurse explains that all clients waiting for a kidney

transplant have to meet the same qualifications, the students should understand that this aspect of
care delivery is an example of which ethical principle
A. Fidelity
B. Autonomy
C. Justice
D. Nonmaleficence
Answer: C. Justice
93. The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client
recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the
family about the use of lorazepam (Ativan). The nurse should instruct the family to report which
of the following significant side effects to the health care provider?
A. Paradoxical excitement.
B. Headache.
C. Slowing of reflexes.
D. Fatigue.
Answer: A. Paradoxical excitement.
94. The nurse is observing care given to a client experiencing severe to panic levels of anxiety.
The nurse would intervene in which of the following situations?
A. The staff maintains a calm manner when interacting with the client.
B. The staff attends to client's physical needs as necessary.
C. The staff helps the client identify thoughts or feelings that occurred prior to the onset of the
anxiety.
D. The staff assesses the client's need for medication or seclusion if other interventions have
failed to reduce anxiety.
Answer: C. The staff helps the client identify thoughts or feelings that occurred prior to the onset
of the anxiety.

95. a nurse is obtaining a medication history from a client who is to start a new prescription for
warfarin ( Coumadin) which of the following over the counter medication should the nurse
instruct the client to avoid
Answer: Aspirin
96. The nurse is performing triage on a group of clients in the emergency department. Which of
the following clients should the nurse see FIRST?
A. A 12-year-old oozing blood from a laceration of the left thumb due to cut on a rusty metal can.
B. A 19-year-old with a fever of 103.8°F (39.8°C) who is able to identify her sister but not the
place and time.
C. A 49-year-old with a compound fracture of the right leg who is complaining of severe pain.
D. A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of470 mg/Dl
Answer: B. A 19-year-old with a fever of 103.8°F (39.8°C) who is able to identify her sister but
not the place and time.
97. A nurse is preparing an Inservice program about delegation. Which of the following elements
should she identify when presenting the 5 rights of delegation. Select all:
A. Right client
B. Right supervision/evaluation
C. Right direction/communication
D. Right time
E. Right circumstances
Answer: B. Right supervision/evaluation
C. Right direction/communication
E. Right circumstances
98. a nurse is preparing to care for a client in the surgical unit who will be receiving lorazapam (
Ativan IV) . for what adverse effect should the nurse monitor this client:
Answer: The nurse should monitor the client respiratory depression

99. A nurse is providing discharge instructions to a client who has a prescription for the use of
oxygen in his home. Which of the following should the nurse teach the client about using oxygen
safely in his home? (Select all that apply.)
A. Family members who smoke must be at least 10 ft from the client when oxygen is in use.
B. Nail polish should not be used near a client who is receiving oxygen.
C. A "No Smoking" sign should be placed on the front door.
D. Cotton bedding and clothing should be replaced with items made from wool.
E. A fire extinguisher should be readily available in the home.
Answer: B. Nail polish should not be used near a client who is receiving oxygen.
C. A "No Smoking" sign should be placed on the front door.
E. A fire extinguisher should be readily available in the home.
100. A nurse is providing home safety instructions to a group of older adult clients. Match the
safety risk with the appropriate instruction.
____ Passive smoking
____ Carbon monoxide poisoning
____ Food poisoning
A. Have water heaters inspected on an annual basis.
B. Cook all meat at an appropriate temperature.
C. Avoid enclosed areas with others who may be smoking.
Answer: C. Avoid enclosed areas with others who may be smoking.
A. Have water heaters inspected on an annual basis.
B. Cook all meat at an appropriate temperature.
101. A nurse is providing teaching about a clear liquid diet. Which of the following should the
nurse instruct the client to avoid?
A. lemon-lime sports drinks
B. ginger ale
C. black coffee
D. orange sherbet
Answer: D. orange sherbet

102. a nurse is reinforcing a teaching on a client who has a prescription for verapamil ( calan)
which of the following statement by the client indicated need further teaching:
Answer: I should decrease the amount of calcium in my diet while taking the medication
103. A nurse is reinforcing teaching regarding the use of a cane to a client who has left-leg
weakness. Which of the following should the nurse include in the teaching?
A. use the cane on the weak side of the body
B. advance the cane and the strong leg simultaneously
C. maintain two points of support on the floor
D. advance the cane 30 to 45 cm (12-18 in) with each step
Answer: C. maintain two points of support on the floor
104. a nurse is reinforcing teaching to a client who is prescribed diazepam tor anxiety of the
following statement indicated the client understand the teaching:
Answer: I will tell my doctor before I stop taking the medication
105. a nurse is reinforcing teaching to a client who is starting amitriptyline ( Elavil) for treatment
of depression which of the following should the nurse include
Answer: 1. change position slowly to minimize dizziness
2. chewing sugarless gum to prevent dry mouth
106. A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the
following is an expected finding?
A. serum albumin level of 3 g/dL
B. HDL level of 90 mg/dL
C. Norton scale score of 18
D. Braden scale score of 20
Answer: A. serum albumin level of 3 g/dL

107. The nurse is supervising the staff providing care for an 18- month-old hospitalized with
hepatitis A. The nurse determines that the staff's care is appropriate if which of the following is
observed?
A. The child is placed in a private room.
B. The staff removes a toy from the child's bed and takes it to the nurse's station.
C. The staff offers the child French fries and a vanilla milkshake for a midafternoon snack.
D. The staff uses standard precautions.
Answer: A. The child is placed in a private room.
108. The nurse is teaching a 40-year-old man diagnosed with a lower motor neuron disorder to
perform intermittent self- catheterization at home. The nurse should instruct the client to
A. use a new sterile catheter each time he performs a catheterization.
B. perform the Valsalva maneuver(holding breath and bearing down) before doing the
catheterization.
C. perform the catheterization procedure every 8 hours.
D. limit his fluid intake to reduce the number of times a catheterization is needed
Answer: B. perform the Valsalva maneuver(holding breath and bearing down) before doing the
catheterization.
109. A nurse manager of a med surge unit is assigning care responsibilities for the oncoming
shift. A client is waiting transfer back to the unit from the PACU following thoracic surgery. To
which staff member should the nurse assign the client?
A. Charge nurse
B. RN
C. LVN
D. AP
Answer: B. RN
110. A nurse offers pain meds to a client who is postop prior to ambulation. The nurse
understands that this aspect of care delivery is an example of which of the following ethical
principles?

A. Fidelity
B. Autonomy
C. Justice
D. Beneficience
Answer: D. Beneficience
111. A nurse on a med surge unit has received change of shift report and will care for 4 clients.
Which of the following clients’ needs will the nurse assign to an AP?
A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia
B. Reinforcing teaching with a client who is learning to walk with a quad cane
C. Reapplying a condom catheter for a client who has urinary incontinence
D. Applying a sterile dressing to a pressure ulcer
Answer: C. Reapplying a condom catheter for a client who has urinary incontinence
112. A nurse questions a med prescription as too extreme and light of the clients advanced age
and unstable status. The nurse understands that this action is an example of which ethical
principle
A. Fidelity
B. Autonomy
C. Justice
D. Nonmalificence
Answer: D. Nonmalificence
113. A nurse recognizes that an initial positive outcome of treatment for a victim of sexual abuse
by one parent would be that the client
A. acknowledges willing participation in an incestuous relationship.
B. reestablishes a trusting relationship with his/her other parent.
C. verbalizes that s/he is not responsible for the sexual abuse.
D. describes feelings of anxiety when speaking about sexual abuse.
Answer: C. verbalizes that s/he is not responsible for the sexual abuse.

114. A nurse responsible for a client receiving an antihypertensive medication is to
Answer: Teach the client to change position slowly to avoid dizziness or fainting
115. The nurse should consider the hierarchy of human needs when prioritizing interventions,
which are?
Answer: Physiological needs first (oxygen, shelter, food)
Safety & security needs (physical safety)
Love and belonging - Self esteem
Self-actualization
116. The nurse's INITIAL priority when managing a physically assaultive client is to
A. restrict the client to the room.
B. place the client under one-to-one supervision.
C. restore the client's self-control and prevent further loss of control.
D. clear the immediate area of other clients to prevent harm.
Answer: C. restore the client's self-control and prevent further loss of control.
117. Nurses must follow what code of standards in delegating and assigning tasks
Answer: ANA codes of standards
118. opioid agonists can cause Constipation What is the nursing intervention and/or client
education ?
Answer: Advise the client to increase fluid/fibre intake and physical activity.
Administer a stimulant laxative such as bisacodyl (Dulcolax) to counteract decreased bowel
motility, or a stool softener such as docusate sodium (Colace) to prevent constipation.
119. Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the
following is a sign of potential hypovolemia?
A. Hypotension
B. Bradycardia
C. Warm moist skin

D. Polyuria
Answer: A. Hypotension
120. A patient who has undergone colostomy surgery is experiencing constipation. Which of the
following interventions should a nurse consider for such a patient?
A. Instruct the patient to keep a record of food intake
B. Instruct the patient to avoid prune or apple juice
C. Suggest fluid intake of at least 2 L per day
D. Assist the patient regarding the correct diet or to minimize food intake
Answer: C. Suggest fluid intake of at least 2 L per day
121. The physician orders ranitidine hydrochloride (Zantac) 150 mg PO qd for a client. The nurse
should advise the client the BEST time to take this medication is
A. before breakfast.
B. with dinner.
C. with food.
D. at hs
Answer: D. at hs
122. The physician orders risperidone (Risperdal) for a client with Alzheimer's disease. The nurse
anticipates administering this medication to help decrease which of the following behaviours?
A. Sleep disturbances.
B. Concomitant depression.
C. Agitation and assaultiveness.
D. Confusion and withdrawal.
Answer: C. Agitation and assaultiveness.
123. A positive Chvosteks sign is found in a patient. The nurse would anticipate IV
administration of:
Answer: calcium gluconate (because hypocalcemia causes Chvostek's sign)

124. An RN is making assignments for client care to an LPN at the beginning of the shift. Which
of the following assignments should the LPN question?
A. Assisting a client who is 24 hr postop to use an incentive spirometer
B. Collecting a clean catch urine specimen from a client who was admitted on the previous shift
C. providing nasopharyngeal suctioning for a client who has pneumonia
D. Replacing the cartridge and tubing on a PCA pump
Answer: D. Replacing the cartridge and tubing on a PCA pump
125. seclusion and restraints: -must be ordered
Answer: • should be ordered for the shortest duration necessary and only if less restrictive
measures are not sufficient
• a client may voluntarily request temp seclusion
• restraints can be physical or chemical
• if used, frequency of client assessments in regards to food, fluid, comfort, and safety should be
performed and documented every 15-30 min
126. Signs for mening ococcemia
Answer: Vomiting, febrile, petechial rash (unstable)
127. Sources of potassium
Answer: beans, spinach, potatoes, dried apricots, acorn squash, yogurt, salmon, avocados,
mushrooms and bananas
128. Taking Coumadin. Which foods should the client limit?
Answer: Foods containing Vitamin K. Dark leafy greens (spinach), brussel sprouts, broccoli,
asparagus, cabbage, pickels, prunes
129. Teaching points for naltrexone (Vivitrol)?
Answer: Take with meals to supress GI distress. Monthly IM injections should be suggested for
patients who have difficulty to adhering to the medication regimen.

130. The nursing team includes two RNs, one LPN/LVN, and one nursing assistant. The nurse
should consider the assignments appropriate if the nursing assistant is assigned to care for
A. a client with Alzheimer's requiring assistance with feeding.
B. a client with osteoporosis complaining of burning on urination.
C. a client with scleroderma receiving a tube feeding.
D. a client with cancer who has Cheyne-Stokes respirations.
Answer: A. a client with Alzheimer's requiring assistance with feeding.
131. what are good sources of folic acid?
Answer: Excellent sources of folate include romaine lettuce, spinach, asparagus, turnip greens,
mustard greens, calf's liver, parsley, collard greens, broccoli, cauliflower, beets, chicken liver and
lentils.
132. what are normal creatinine levels? what are normal BUN levels?
Answer: 0.8-1.4 mg/dL 8-25 mg/Dl
133. What are positive actions to help others
Answer: Beneficience
134. What are some things to teach about home safety with elderly patients?
Answer:• Removing items that could cause the client to trip, such as throw rugs and loose
carpets
• Placing electrical cords and extension cords that against a wall behind furniture
• Making sure that steps and sidewalks are in good repair
• Placing grab bars near the toilet and in the tub or shower and installing a stool riser
• Using a non-skid mat in the tub or shower
• Placing a shower chair in the shower
• Ensuring that lighting is adequate both inside and outside of the home
135. What are some ways to identify a patient before giving a medication?

Answer: The Joint Commission requires 2 client identifiers be used when administering
medications.
• clients name
• assigned identification number
• telephone number
• birth date or other personal-specific identifiers. Bar code scanners may be used to identify
clients
136. What are the five stages of grief
Answer: denial anger bargaining depression acceptance
137. What are the precautions for vancomycin resistant enterococcus
Answer: Standard precautions including hand washing and gloving should be followed
138. What are the signs and symptoms of fluid volume deficit:
Answer: loss of total body Na. Causes include vomiting, excessive sweating, diarrhoea, burns,
diuretic use, and kidney failure. Clinical features include diminished skin turgor, dry mucous
membranes, tachycardia, and orthostatic hypotension.
139. What are the S/S of lithium toxicity?
Answer: (Depakote for bipolar disorder): fine hand tremors, mild GI upset, slurred speech and
muscle weakness
140. What are the therapeutic effects of protamine
Answer: Antidote to severe heparin overdose + Reversal of heparin administered during
procedures
141. What are the values and beliefs that guide behavior and decision making?
Answer: Morals
142. What are total serum protein values (normal)

Answer: 6-8 g/dL
143. What can prevent MI, stroke, or death in high-risk patients:
Answer: Ramipril
144. What comorbidities may be observed with a patient who is bipolar?
Answer: Substance use disorder (experiences more rapid cycling), anxiety disorders, eating
disorders, ADHD.
145. What does a newborns poop look like:
Answer: If your baby is exclusively breastfed, her poop will be yellow or slightly green and
have a mushy or creamy consistency
146. What do the nurse need to keep in mind about the client when being their advocate?
Answer: Client's religion & culture
147. What do you do when a client has a seizure:
Answer: • lower to bed/floor
• protect head, move nearby furniture, provide privacy,
• put on side with head flexed slightly forward, and loosen clothing to prevent injury
• in event of seizure, stay with client and call for help
• admin meds as ordered
•note duration of seizure and sequence and type of movement
148. what foods should you avoid if you have diverticulitis?
Answer: avoid hard-to-digest foods such as nuts, corn, popcorn, and seeds, for fear that these
foods would get stuck in the diverticula and lead to inflammation. (Eat foods high in fibre)
149. What immunizations are CONTRAINDICATED for pregnant women + which SHOULD be
given?

Answer: Contraindicated = Herpes Zoster + Varicella + MMR (measles, mumps, rubella) Should
give = TDaP (Tetanus, Diphtheria, Pertussis)
150. What is an agreement to keep promises
Answer: Fidelity
151. What is an interdisciplinary team?
Answer: A group of health care professionals from different disciplines
152. what is a normal haematocrit level in a female? What are normal Hgb values (female)? what
are normal values for WBCs?
Answer: 37-48% (male is 42-52%) 12-16 g/dL (male 13-17) 4500-11,000 / uL
153. What is appropriate for an adolescent in the hospital?
Answer: Puzzles and books
154. What is avoidance of harm or injury
Answer: Non-maleficence
155. What is bipolar disorder?
Answer: Bipolar disorder is a mood disorder with recurrent episodes of depression and mania.
156. What is fairness in care delivery and use of resources:
Answer: Justice
157. what is important about the diet of someone taking ACE inhibitors?
Answer: can result in high potassium levels. Limit potassium intake (beans, spinach, potatoes,
dried apricots, acorn squash, yogurt, salmon, avocados, mushrooms and bananas)
158. what is normal pre-albumin values? what are normal serum levels of magnesium ? what is a
normal potassium serum level?

Answer: 17-40 mg/dL 1.5-2.5 mEq/L (less than 1.5 is considered hypomagnesemia)
3.5-5.0 mEq/L (less than 3.5 is considered hypokalemia)
159. What is the difference between respiratory acidosis and respiratory alkalosis?
Answer: Acidosis refers to an excess of acid in the blood that causes the pH to fall below 7.35,
and alkalosis refers to an excess of base in the blood that causes the pH to rise above 7.45.
160. What is the most appropriate method for contraception for an adolescent
Answer: IUD or implant
161. What is the nurse's contribution to an interdisciplinary team?
Answer: knowledge of nursing care & its management - a holistic understanding of the client,
her/his healthcare needs & healthcare systems.
162. What is the nursing action for dehiscence:
Answer: Cover with a sterile towel moistened with sterile saline; Have patient flex knees
slightly and put in Fowler's .
163. What is the process of taking a telephone order from a provider?
Answer: Patient name, drug, dose, route, frequency read back for accuracy
164. What is the proper nutrition during pregnancy
Answer: Folic acid is important for pregnancy, as it can help to prevent birth defects known as
neural tube defects, including spina bifida - green leafy vegetables and brown rice
165. What is the right to make one’s own personal decisions, even the those decisions might not
be in the persons best interest:
Answer: Autonomy
166. What is the safest way to thaw out frozen foods:
Answer: In the refrigerator

167. What is the study of conduct and character?
Answer: Ethics
168. What kind of medications are indicated for abstinence maintenance of alcohol?
Answer: Disulfiram (Antabuse), Naltrexone (Vivitrol), Acamprosate (Campral)
169. What medications can be taken to help with smoking cessation
Answer: Bupropion hydrochloride is a medicine for depression, but it also helps people quit
smoking. Brand names include Zyban®, Wellbutrin®, Wellbutrin SR® and Wellbutrin XL® but
this medication is also available as a generic. Varenicline (chantix)
170. What position is good to use for a patient who is at high risk for a pressure ulcer
Answer: 30 degree lateral position is recommended for clients at risk for pressure ulcers
171. What should be avoided during pregnancy
Answer: Do not take vitamin A supplements, or any supplements containing vitamin A (retinol),
as too much could harm your baby
172. What should the nurse do when one member of a support group expresses anger repeatedly?
Answer: Focus more on the group members who have a positive outlook (Speak to group
member privately to uncover source of anger)
173. What temperature should pork be cooked at
Answer: 160 degrees
174. What therapy will be useful for patients with bipolar?
Answer: Electroconvulsive therapy for the patient who is suicidal or rapid cycling who HAS
taken Lithium and has proven ineffective. Used to subdue manic behavior.
175. What to monitor for when taking enoxaparin (lovenox)

Answer: Hyperkalemia
Cases of headache, haemorrhagic anaemia, eosinophilia, alopecia, hepatocellular and cholestatic
liver injury reported
176. What type of infectious diseases are required to be reported to the health department?
Answer: severe cases of Staphylococcus aureus infections including methicillin-resistant
Staphylococcus aureus (MRSA)
177. What values would a nurse possess to be a client advocate?
Answer: caring
autonomy- respect
empowerment
178. When caring for the client diagnosed with delirium, which condition is the most important
for the nurse to investigate?
A. Cancer of any kind.
B. Impaired hearing.
C. Prescription drug intoxication.
D. Heart failure
Answer: C. Prescription drug intoxication.
179. When does Discharge planning begin?
Answer: At Admission
180. When performing nasotracheal suctioning what technique should be used?
Answer: Sterile asepsis bc the trachea is considered sterile and prevents infections
181. When providing family education for those who have a relative with Alzheimer's disease
about minimizing stress, which of the following suggestions is most relevant?
A. Allow the client to go to bed four to five times during the day.
B. Test the cognitive functioning of the client several times a day.

C. Provide reality orientation even if the memory loss is severe.
D. Maintain consistency in environment, routine, and caregivers
Answer: D. Maintain consistency in environment, routine, and caregivers
182. When should planning discharge process begin?
A. at time of admission
B. 2 days after client is admitted
C. whenever the nurse has the time to do planning
D. when the physician has the discharge order:
Answer: A. at time of admission
183. When taking MAOI's,
Answer: limit your consumption of: thyramine it can cause elevated BP. This is found in "aged"
products such as aged cheeses (swiss), cured meats (pepperoni/salomi), sauerkraut, soy sauce.
Examples of MAOI's are: Isocarboxazid (Marplan), Phenelzine (Nardil), Selogilive, Emsam,
Eldepryl, Zelapar.
184. When using restraints for an agitated/aggressive patient, which of the following statements
should NOT influence the nurse's actions during this intervention?
A. The restraints/seclusion policies set forth by the institution.
B. The patient's competence.
C. The patient's voluntary/involuntary status.
D. The patient's nursing care plan.
Answer: C. The patient's voluntary/involuntary status.
185. Where should the Cath bag be placed when urinary catheterization
Answer: Make sure the catheter bag/system is at a level below the client's bladder to avoid
reflux.
186. Which grief process is it when Client exhibits increased anxiety + may project anger toward
self + others "I don't deserve to die, this isn't fair"

Answer: Anger stage
187. Which Grief Process when Client acknowledges the impending loss while remaining
hopeful "If I could just make it through this, I'd never smoke again
Answer: Bargaining Stage
188. Which of the following assessment findings would indicate to the nurse the need for more
sedation in a client who is withdrawing from alcohol dependence?
A. Steadily increasing vital signs.
B. Mild tremors and irritability.
C. Decreased respirations and disorientation.
D. Stomach distress and inability to sleep
Answer: A. Steadily increasing vital signs.
189. Which of the following is a correctly stated nursing diagnosis for a client with abruptio
placentae?
A. Infection related to obstetrical trauma.
B. Potential for fetal injury related to abruptio placentae.
C. Potential alteration in tissue perfusion related to depletion of fibrinogen.
D. Fluid volume deficit related to bleeding.
Answer: D. Fluid volume deficit related to bleeding.
190. Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a
client with delirium?
A. Explain the experience of having delirium.
B. Resume a normal sleep-wake cycle.
C. Regain orientation to time and place.
D. Establish normal bowel and bladder function.
Answer: C. Regain orientation to time and place.
191. Which of the following is essential when caring for a client who is experiencing delirium?

A. Controlling behavioral symptoms with low-dose psychotropics.
B. Identifying the underlying causative condition or illness.
C. Manipulating the environment to increase orientation.
D. Decreasing or discontinuing all previously prescribed medications.
Answer: B. Identifying the underlying causative condition or illness.
192. Which of the following nursing interventions is MOST important for a 45-year-old woman
with rheumatoid arthritis?
A. Provide support to flexed joints with pillows and pads.
B. Position her on her abdomen several times a day.
C. Massage the inflamed joints with creams and oils.
D. Assist her with heat application and ROM exercises.
Answer: D. Assist her with heat application and ROM exercises.
193. Which of the following should indicate to a nurse the need to suction a client's
tracheostomy?
A. irritability
B. hypotension
C. flushing
D. bradycardia
Answer: A. irritability
194. Which of the following situations can be identified as an ethical dilemma?
A. A nurse on a med surge unit demonstrates signs of chemical impairment
B. A nurse over hears another nurse telling an older adult client that if he doesn’t stay in bed, she
will restrain him
C. A family has conflicting feelings about the initiation of enteral tube feedings of their father
who is terminally ill
D. A client who is terminally ill hesitates to name her spouse on her durable power of attorney
form

Answer: C. A family has conflicting feelings about the initiation of enteral tube feedings of their
father who is terminally ill
195. Which of the following techniques should the nurse use when performing nasotracheal
suctioning for a client?
A. insert the suction catheter while the client is swallowing
B. apply intermittent suction when withdrawing the catheter
C. place the catheter in a location that is clean and dry for later use
D. hold the suction catheter with the clean, on-dominant hand
Answer: B. apply intermittent suction when withdrawing the catheter
196. Which outcome indicates effective client teaching to prevent constipation?
A. The client reports engaging in a regular exercise regimen.
B. The client limits water intake to three glasses per day.
C. The client verbalizes consumption of low-fibre foods.
D. The client maintains a sedentary lifestyle.
Answer: A. The client reports engaging in a regular exercise regimen.
197. A young woman is transferred to a psychiatric crisis unit with a diagnosis of a dissociative
disorder. The nurse knows which of the following comments by the client is MOST indicative of
this disorder?
A. "I keep having recurring nightmares."
B. "I have a headache and my stomach has bothered me for a week."
C. "I always check the door locks three times before I leave home."
D. "I don't know who I am and I don't know where I live."
Answer: D. "I don't know who I am and I don't know where I live."