Preview Extract
ATI Fundamentals Proctored Exam Study Guide 3
Bsc. Medical Laboratory Sciences (Murang'a University of Technology)
ATI Fundamentals Proctored Exam Study Guide
A nurse observes an assistive personnel reprimanding a client for not using the urinal
properly. The AP tells him she will put a diaper on him if she does not use the urinal more
carefully next time. Which of the following torts is the AP committing.
Answer: Assault
A nurse is caring for a competent adult client who tells the nurse that he is thinking about
leaving the hospital against medical advice. The nurse believes that this is not in the client's
best interest, so she prepares to administer PRN sedative medication the client has not
requested along with his usual medication. Which of the following types of tort is the nurse
about to commit?
Answer: False imprisonment
A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled
for surgery the following week. The client tells the nurse that he will prepare his advance
directives before he goes to the hospital. Which of the following statements made by the
client should indicate to the nurse an understanding of advance directives?
Answer: I plan to write that I don't want them to keep me on a breathing machine.
A nurse has noticed several occasions in the past week when another nurse on the unit
seemed drowsy and unable to focus on the issue at hand. Today, should found the nurse
asleep in a chair in the break room when she was not on a break. Which of the following
actions should the nurse take?
Answer: Report observations to the nurse manager on the unit
A nurse is caring for a client who is about to undergo an elective surgical procedure. The
nurse should take which of the following actions regarding informed consent?
Answer: Make sure the surgeon obtained the client's consent. Witness the client's signature
on the consent form.
When entering a client's room to change a surgical dressing, a nurse notes that the client is
coughing and sneezing. Which of the following actions should the nurse take when preparing
a sterile field?
Answer: Place a mask on the client to limit the spread of microorganisms into the surgical
wound
A nurse has removed a sterile pack from its outside cover and placed it on a clean work
surface in preparation for an invasive procedure. Which of the following flaps should the
nurse unfold first?
Answer: The flap furthest from the body
A nurse is wearing sterile gloves in preparation for performing sterile procedure. Which of
the following objects can the nurse touch without breaching sterile technique?
Answer: The inner wrapping of an item on the sterile field an irrigation syringe on the sterile
field one gloved hand with the other gloved hand
A nurse is reviewing hand hygiene techniques with a group of assistive personnel. Which of
the following instructions should the nurse include when discussing handwashing?
Answer: Wash the hands with soap and water for at least 15 seconds. Use a clean paper towel
to turn off hand faucets.
A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which
of the following events should the nurse recognize as contaminating the sterile field.
Answer: • The nurse moistens a cotton ball with sterile normal saline and places it on the
sterile field.
• The procedure is delayed 1 hour because the provider receives an emergency call.
• The nurse turns to speak to someone who enters through the door behind the nurse.
A nurse is discussing restorative health care with a newly licensed nurse. Which of the
following examples should the nurse include in the teaching?
Answer: • Home health care
• Rehab facilities
• Skilled nursing facilities
A nurse is explaining the various types of health care coverage. Which of the following health
care financing mechanisms are federally funded?
Answer: • Medicare
• Medicaid
A nurse manager is developing strategies to care for the increasing number of clients who
have obesity. Which of the following actions should the nurse include as a primary care
strategy?
Answer: Collaborating with providers to perform obesity screenings during routine office
visits.
A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the
following tasks should the nurse identify as the responsibility of state licensing boards?
Answer: Ensuring that health care providers comply with regulations
A nurse is explaining the various levels of health care services to a group of newly licensed
nurses. Which of the following examples of care or care settings should the nurse classify as
tertiary care?
Answer: • Intensive Care Unit (ICU)
• Oncology treatment center
• Burn center
A nurse is caring for a group of clients on a medical-surgical unit. For which of the following
client care needs should the nurse initiate a referral for a social worker?
Answer: • A client who has terminal cancer requests hospice care in home
• A client asks about community resources available for older adults
• A client requests an electric wheelchair for use after discharge
A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use
adaptive devices. The nurse caring for the client should initiate a referral to which of the
following members of the interprofessional care team?
Answer: Occupational therapist
A client who is postoperative following knee arthroplasty is concerned about the adverse
effects of the medication he is receiving for pain management. Which of the following
members of the interprofessional care team can assist the client in understanding the
medication's effects?
Answer: • Provider
• Pharmacist
• RN
A client who had a CVA has persistent problems with dysphagia. The nurse caring for the
client should initiate a referral with which of the following members of the interprofessional
care team?
Answer: Speech-language pathologist
A nurse is acquainting a group of newly licensed nurses with the roles of the various
members of the health care team they will encounter on a medical-surgical unit. When she
gives examples of types of tasks certified nursing assistants (CNAs) may perform, which of
the following client activities should she include?
Answer: • Bathing
• Ambulating
• Toileting
• Measuring vital signs
A nurse is caring for a client who decides not to have surgery despite significant blockages of
the coronary arteries. The nurse understands that this client's choice is an example of which
of the following ethical principles?
Answer: Autonomy
A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse
understands that this aspect of care delivery is an example of which of the following ethical
principles?
Answer: Beneficence
A nurse is instructing a group of newly licensed nurses about the responsibilities organ
donation and procurement involved. When the nurse explains that all clients waiting for a
kidney transplant have to meet the same qualifications, the newly licensed nurses should
understand that this aspect of care delivery is an example of which of the following ethical
principles?
Answer: Justice
A nurse questions a medication prescription as too extreme in light of the client's advanced
age and unstable status. The nurse understands that this action is an example of which of the
following ethical principles?
Answer: Nonmaleficence
A nurse is instructing a group of newly licensed nurses about how to know and what to
expect when ethical dilemmas arise. Which of the following situations should the newly
licensed nurses identify as an ethical dilemma?
Answer: A family has conflicting feelings about the initiation of enteral tube feedings for
their father, who is terminal ill.
A nurse is preparing information to a change-of-shift-report. Which of the following
information should the nurse include in the report?
Answer: A bone scan that is scheduled for today
A nurse manager is discussing the HIPAA privacy rule with a group of newly hired nurses
during orientation. Which of the following information should the nurse manager include?
Answer: • Family members should provide a code prior to receiving client health information
• Communication of client information can occur at the nurse's station
• A client can request a copy of her medical record
• A nurse may photocopy a client's medical record for transfer to another facility
A nurse is reviewing documentation with a group of newly licensed nurses. Which of the
following legal guidelines should be followed when documenting in a client's record?
Answer: • Put the date and time on all entries.
• Document objective data, leaving out opinions.
A nurse is discussing occurrences that require completion of an incident report with a newly
licensed nurse. Which of the following should the nurse include in the teaching?
Answer: • Medication error
• Needlestick
• Omission of prescription
A nurse is receiving a provider's prescription by telephone for morphine for a client who is
reporting moderate to severe pain. Which of the following nursing actions are appropriate?
Answer: • Repeat the details of the prescription back to the provider.
• Have another nurse listen to the telephone prescription.
• Obtain the provider's signature on the prescription within 24 hr.
A nurse on a medical-surgical unit has received change-of-shift report and will care for four
clients. Which of the client's needs should the nurse assign to an assistive personnel (AP)
Answer: Reapplying a condom catheter for client who has urinary incontinence.
A nurse manager of a medical-surgical unit is assigning care responsibilities for the oncoming
shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery.
To which of the following staff members should the nurse assign this client?
Answer: The RN
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an
AP. Which of the following information should the nurse share with the AP?
Answer: • The client ambulates with his slippers on over his anti embolic stockings
• The client uses a front-wheeled walker when ambulating
• The client had pain medication 30 min ago
An RN is making assignments for a practical nurse (PN) at the beginning of the shift. Which
of the following assignments should the PN question?
Answer: • Teaching a client who has asthma to use a metered dose inhaler
• Replacing the cartridge and tubing on a PCA pump
A nurse is preparing an in-service program about delegation. Which of the following
elements should she identify when presenting the 5 rights of delegation?
Answer: • Right supervision and evaluation
• Right direction and communication
• Right circumstances
By the second post-op day, a client has not achieved satisfactory pain relief. Based on this
evaluation, which of the following actions should the nurse take, according to the nursing
process?
Answer: Reassess the client to determine the reasons for inadequate pain relief.
A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions
that do not require a provider's prescription. Which of the following interventions should the
charge nurse include?
Answer: • Showing a client progressive muscle Relaxation
• Perform daily bath after meals
• Reposition Klein every two hours to reduce pressure ulcer risk
Which statement correctly identify as an appropriate steps in the planning of the nursing
process
Answer: I would determine the most important client problems that we should address
A nurse is caring for a client who is 24 hr postoperative following an inguinal hernia repair.
The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire
for "real food." The nurse tells the client, "I will call the surgeon and ask for a change in
diet." The surgeon hears the nurse's report and prescribes a full liquid diet. The nurse used
which of the following levels of critical thinking?
Answer: Basic
A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse
checks the client's medical record, discovers that the client is allergic to the antibiotic, and
calls the provider to request a prescription for a different antibiotic. Which of the following
critical thinking attitudes did the nurse demonstrate?
Answer: Responsibility
A nurse is caring for a client who is 24 HRS postoperative following abdominal surgery. The
nurse suspects the client's acute pain management is inadequate. Which of the following data
reinforce this suspicion?
Answer: • The client is non-adherent with coughing, deep breathing, and dangling
• The client may have pain medication every 4 to 6 hours but only takes it every 6 to 7
• Heart rate is 124
• Respiratory rate is 22
• Temperature is 98.6
• Blood pressure is 156/80
A nurse is caring for a client who has a new prescription for antihypertensive medication.
Prior to administering the medication, the nurse uses an electronic database to gather
information about the medication and the effects it might have on this client. Which of the
following components of critical thinking is the nurse using when he reviews the medication
information?
Answer: Knowledge
A nurse uses a head-to -toe approach to conduct a physical assessment of a client who will
undergo surgery the following week. Which of the following critical thinking attitudes did the
nurse demonstrate?
Answer: Discipline
A nurse is performing an admission assessment for an older adult client. After gathering the
assessment data and performing the review of systems, which of the following actions is a
priority for the nurse?
Answer: Orient the patient to his room
A nurse is admitting a client who has acute cholecystitis to a medical-surgical unit. Which of
the following actions are essential steps for the admission procedure?
Answer: • Explain the roles of other care delivery staff.
• Begin discharge planning
• Provide info about advance directives
• Introduce the client to his roommate
A nurse is caring for a client who had a stroke and is scheduled for transfer to a rehab center.
Which of the following tasks are the responsibility of the nurse at the transferring facility?
Answer: • Ensure that the client has possession of his valuables.
• Confirm that the rehab center has a room available at the time of transfer.
• Give a verbal transfer report via telephone
• Complete a transfer form for the receiving facility.
A nurse is preparing the discharge summary for a client who has had knee arthroplasty and is
going home. Which of the following information about the client should the nurse include in
the discharge summary?
Answer: • Follow up care
• Instructions for diet and medications
• Contact info for home health care agency
As part of the admission process, a nurse at a long-term care facility is gathering a nutrition
history for a client who has dementia. Which of the following components of the nutrition
evaluation is the priority for the nurse to determine from the client's family?
Answer: Any difficulty swallowing
A nurse is caring for a client who fell at a nursing home. The client is oriented to person,
place, and time and can follow directions. Which of the following actions should the nurse
take to decrease the risk of another fall?
Answer: • Call light in reach
• Provide nonskid footwear
• Complete fall risk assessment
A nurse manager is reviewing with nurses on the unit the care of a client who has had a
seizure. Which of the following statements by nurse requires further instruction?
Answer: I will go to the nurses' station for assistance
A nurse observes smoke coming from under the door of the staff's lounge. Which of the
following actions is the nurse's priority?
Answer: Move clients who are nearby
A nurse is caring for a client who has a history of falls. Which of the following actions is the
nurse's priority?
Answer: Complete a fall-risk assessment
A charge nurse is assigning rooms for clients to be admitted to the unit. To prevent falls,
which of the following clients should the nurse assign the room closest to the nurses' station?
Answer: An older adult who is postoperative following a below-the-knee amputation
A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The
nurse is aware that health care professionals are required to report communicable and
infectious diseases. Which of the following illustrate the rationale for reporting?
A. Planning and evaluating control and prevention strategies
B. Determining public health priorities
C. Ensuring proper medical treatment
D. Identifying endemic disease
E. Monitoring for common-source outbreaks
Answer: A. Planning and evaluating control prevention strategies
B. Determining public health priorities
C. Ensuring proper medical treatment
E. Monitoring for common-source outbreaks
A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles
with some crustings. Which of the following should the nurse suspect?
Answer: Herpes zoster
A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and
swollen lymph nodes. The client is experiencing which of the following stages of infection?
Answer: • Illness
• The illness stage is when the client experiences signs and symptoms specific to the
infection.
What is the prodromal period?
Answer: short period after incubation; early, mild symptoms, most contagious period
What is the incubation period?
Answer: the period between exposure to an infection and the appearance of the first
symptoms
What is convalescence?
Answer: period of recovery
Systemic infection
Answer: affects the entire body
What are clinical manifestations of localized versus a systemic infection?
Answer: • Fever
• Malaise
• Increase in Pulse and Respiratory Rate
The skin barrier covering a client's intestinal fistula keeps falling off when she stands up to
ambulate. The nurse has reapplied it twice during the current shift, but it remains intact only
when the client is supine in bed. The nurse telephoned the physical therapist about the
difficulties containing the drainage from the fistula, so the therapist did not ambulate the
client today. The client sat in a chair during lunch with an absorbent pad over the fistula. The
client ate all the food on her tray. The wound care nurse confirmed that she will see the client
later today. The client states she feels frustrated at not having physical therapy, but the nurse
thinks the client welcomed having a day to rest. Which of the following information should
the nurse include in the change-of-shift report?
Answer: • The physical therapist did not ambulate the client today.
• The skin barrier's seal stays on in bed but loosens when the client stands.
• The wound care nurse will see the client later today.
A nurse is caring for an older adult client who lives alone & is to be discharged in 3 days. He
states that it is difficult to prepare adequate nutritious meals at home for just 1 person. To
which of the following members of the health care team should the nurse refer him?
Answer: Social Worker
Can an RN delegate to an LPN to provide tracheostomy care to a client with pneumonia?
Answer: Yes
What intervention should be made for patient being admitted with pertussis?
Answer: Wear a mask within 3 feet of the client place a surgical mask on the client when
transporting wear a gown when performing care that might result in secretions
A nurse is counseling an older adult who describes having difficulty dealing w/ several
issues. Which of the following problems verbalized by the client should the nurse identify as
the priority?
Answer: "I keep forgetting which medications I have taken during the day."
A nurse is providing teaching for an older adult who had lost 4.5 kg (9.9 lb) since the last
admission 6 months ago. Which of the following instructions should the nurse include in the
teaching?
Answer: • "Eat foods that are easy to eat, such as finger foods"
• "Invite family members to eat meals with you"
• "Exercise every day to increase appetite"
A nurse is planning a presentation for a group of older adults about health promotion and
disease prevention. Which of the following interventions should the nurse plan to
recommend?
Answer: • Pneumococcal immunization
• Yearly eye examination
• Periodic mental health screening
• Annual fecal occult blood test
A nurse is talking with an older adult client about improving nutritional status. Which of the
following interventions should the nurse recommend?
Answer: • Increase protein intake to increase muscle mass
• Increase calcium intake to prevent osteoporosis
• Limit sodium intake to prevent edema
• Increase fiber intake to prevent constipation
A nurse is collecting data from an older adult client as part of a comprehensive physical
exam. Which of the following findings should the nurse expect as associated with aging?
Answer: • Decreased Height
• Nail thickening
• Decreased bladder capacity
A nurse is planning care for a patient who has hypernatremia. Which of the following actions
should the nurse anticipate including in the plan of care?
Answer: Infuse hypotonic IV fluids
A nurse is reviewing the medical record of a client who has hypocalcemia. the nurse should
identify which of the following findings as risk factors for the development of this electrolyte
imbalance?
Answer: Crohn's disease
A nurse receives a laboratory report for a client indicating a potassium level of 5.2 mEq/l.
When notifying the provider, the nurse should anticipate which of the following actions?
Answer: Initiating continuous cardiac monitoring
A nurse is collecting data from a client who has hypercalcemia as a result of a long-term use
of glucocorticoids. Which of the following findings should the nurse expect?
Answer: • Confusion
• Bone Pain
• Nausea and vomiting
A nurse is providing education for a client who has severe hypomagnesemia due to alcohol
use disorder. the client is to receive magnesium sulfate. Which of the following information
should the nurse include in the teaching?
Answer: "You will have your deep‑tendon reflexes monitored while you are receiving
magnesium."
A nurse is caring for a client who has been sitting in a chair for 1 hour. Which of the
following complications is the greatest risk to the client?
Answer: Pressure ulcer
A nurse is caring for a client who is postoperative. Which of the following interventions
should the nurse take to reduce the risk of thrombus development?
Answer: • Apply elastic bandages/stockings
• Assist the client to change position often
A nurse is planning care for a client who is on bed rest. Which of the following interventions
should the nurse plan to implement?
Answer: Encourage the client to perform antiembolic exercises every 2 hours
A nurse is evaluating teaching on a client who has a new prescription for a sequential
compression device. Which of the following client statements should indicate to the nurse the
client understands the teaching?
Answer: "This thing will keep the blood pumping through my leg."
A nurse is instructing a client, who has an injury of the left lower extremity, about the use of
the cane. Which of the following instructions should the nurse include?
Answer: • Hold the cane on the right side.
• Keep two points of support on the floor.
• After advancing the cane, move the weaker leg forward.
A nurse is caring for a client receiving enteral tube feedings due to dysphagia. Which of the
following bed positions is appropriate for safe care of this client?
Answer: Semi Fowler's
A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the
following actions is the nurse's priority at this time?
Answer: Determine the client's ability to help with the transfer
A nurse is completing discharge instructions for a client who has COPD. The nurse should
identify that the client understands the orthopneic position when she states that she will do
which of the following when she has difficulty breathing at night?
Answer: Sit on the side of the bed and rest her arms over pillows on top of her bedside table
A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the
following instructions should the nurse manager include?
Answer: • Request assistance when repositioning the client
• Avoid twisting your spine or bending at the waist
• Use smooth movements when lifting and moving clients
A nurse educator is reviewing proper body mechanics during employee orientation. Which of
the following statements should the nurse identify as an indication that an attendee
understands the teaching?
Answer: • "The lower my center of gravity, the more stability I have."
• "To broaden my base of support, I should spread my feet apart."
• "When I lift an object, I should hold it as close to my body as possible"
A nurse is caring for an adolescent client who is 2 days postoperative following an
appendectomy and has type 1 diabetes mellitus. The client is tolerating a regular diet. He has
ambulated successfully around the unit with assistance. He requests pain medication every 6
to 8 hours while reporting pain at a 2 on scale of 0 to 10 after receiving medication. His
incision is approximated and free of redness, with scant serous drainage on the dressing. The
nurse should recognize that the client has which of the following risk factors for impaired
wound healing?
Answer: • The client who has type I diabetes mellitus is at risk for impaired circulation.
• The client who has type I diabetes mellitus is at risk for impaired immune system function.
A nurse is collecting data from a client who is 5 days postoperative following abdominal
surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic
therapy for the nurse to initiate after collecting wound and blood specimens for culture and
sensitivity. Which of the following findings should the nurse expect?
Answer: • Increase in incisional pain
• Fever and chills
• Reddened wound edges
A nurse educator is reviewing the wound healing process with a group of nurses. The nurse
educator should include in the information which of the following alterations for wound
healing by secondary intention?
Answer: • Stage III pressure ulcer
• Open burn area
A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain
in his surgical incision. The nurse checks the surgical wound and finds it separated with
viscera protruding. Which of the following actions should the nurse take?
Answer: • Cover the area with saline-soaked sterile dressings.
• Position the client supine with his hips and knees bent.
A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which
of the following interventions should the nurse use to help maintain the integrity of the
client's skin?
Answer: • Keep the head of the bed elevated 30 degrees.
• Have the client sit on a gel cushion when in a chair.
A nurse is delivering an enternal feeding to a client who has an NG tube in place for
intermittent feedings. When the nurse pours water into the syringe after the formula drains
from the syringe, the client asks the nurse why the water is necessary. Which of the following
responses should the nurse make?
Answer: "Water helps clear the tube so it doesn't get clogged"
A nurse is caring for a client who is receiving continuous enteral feedings. Which of the
following nursing interventions is the highest priority when the nurse suspects aspiration of
the feeding?
Answer: Stop the feeding
A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place.
Which of the following actions is the nurse's highest assessment priority before preforming
this procedure
Answer: Verify the placement of the NG tube.
A nurse is caring for a client in a long term care facility who is receiving enternal feeding via
an NG tube. Which of the following actions should the nurse complete prior to administering
the tube feeding?
Answer: • Auscultate bowel sounds
• Assist the client to an upright position
• Test the pH of gastric aspirate
A nurse is preparing to insert an NG tube for a client who requires gastric decompression.
Which of the following actions should the nurse perform before beginning the procedure.
Answer: • Review a signal the client can use if feeling any distress
• Lay a towel across the client's chest
A nurse in a providers office is evaluating a client who reports losing control of urine
whenever she coughs, laughs or sneezes. client relates a history of 3 vaginal births and has no
serious accidents or illnesses. Which interventions should the nurse suggest for control of
clients incontinence?
Answer: • decrease or avoid caffeine
• avoid alcohol
A client who has an indwelling catheter reports a need to urinate. Which of the following
actions should the nurse take?
Answer: Check to see whether the catheter is patent
A nurse is caring for a client with a 24 hour urine collection. which of the following actions
should the nurse take?
Answer: discard first voiding
A nurse is reviewing factors that increase the risk of urinary tract infections with a client who
has recurrent UTIs. Which of the following factors should the nurse include?
Answer: • Frequent sexual intercourse
• Location of urethra in relation to the anus
• frequent catheterization
A nurse is preparing to initiate a bladder retaining program for a patient with incotinence.
what actions should the nurse take?
Answer: • have client record urination times
• gradually increase urination intervals
• remind client to hold urine until next scheduled urination time
A nurse is assessing a client who has an acute respiratory infection that puts her at risk for
hypoxemia. Which of the following findings are early indications that should alert the nurse
that the client is developing hypoxemia?
Answer: Restlessness tachypnea pallor
A provider is discharging a client with a prescription for home oxygen therapy via nasal
cannula. Client and family teaching by the nurse should include which of the following
instructions?
Answer: • Check the position of the cannula frequently.
• Report any nasal stuffiness, nausea, or fatigue.
• Post "no smoking" signs in a prominent location
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and
is already receiving oxygen therapy via nasal cannula. Which of the following interventions
is the nurse's priority?
Answer: Assist the client to Fowler's position.
A nurse is preparing to perform endotracheal suctioning for a client. Which of the following
are appropriate guidelines for the nurse to follow?
Answer: • Apply suction while withdrawing the catheter
• Use a new catheter for each suctioning attempt
• Limit suctioning to 2 to 3 attempts
A nurse is caring for a client who has a tracheostomy. Which of the following actions should
the nurse take each time he provides tracheostomy care?
Answer: • Apply the oxygen source loosely if the SpO2 decreases during the procedure.
• Use surgical asepsis to remove and clean the inner cannula.
• Clean the outer surfaces in a circular motion from the stoma site outward.
Non-Breather Mask
Answer: allows higher levels of oxygen to be added to the air taken in by the patient
Venturi mask
Answer: an oxygen-delivery apparatus consisting of a mask with holes on each side that
allow exhaled air to escape and color-coded entrainment ports that are adjustable to allow
regulation of the concentration of oxygen delivered
A nurse is caring for a 20 YO client who is sexually active and has come to the college health
clinic for the first time for a checkup. Which of the following interventions should the nurse
perform first to determine the client's need for health promotion and disease prevention?
Answer: Determine the client's risk factors.
A nurse at a provider's office is talking with a 45-year-old client who has no specific family
history of cancer or diabetes mellitus about planning her routine screenings. Which of the
following client statements indicates that the client understands how to proceed?
Answer: "For now, I should continue to have a mammogram each year."
A nurse is talking with a client who recently attended a cholesterol screening event and a
heart-healthy nutrition presentation at a neighborhood center. His total cholesterol result from
the screening was248 mg/dL, so he saw his provider and received a medication prescription
to improve his cholesterol level. The client was later hospitalized for severe chest pain, and
subsequently enrolled in a cardiac rehabilitation program. Which of the following activities
of this client is an example of primary prevention?
Answer: Nutrition Presentation
A nurse in a clinic is planning health promotion and disease prevention strategies for a client
who has multiple risk factors for CV disease. Which of the following interventions should the
nurse include?
A. Help the client see the benefits of her actions
B. Identify the clients support systems
C. Suggest and recommend community resources
D. Devise and set goals for the client
E. Teach stress management strategies
Answer: A. Help the client see the benefits of her actions
B. Identify the clients support systems
C. Suggest and recommend community resources
E. Teach stress management strategies
A nurse in a health clinic is caring for a 21 YO client who reports a sore throat. The client
tells the nurse that he has not seen a doctor since high school. Which of the following health
screenings should the nurse expect the provider to perform for this client?
A. Testicular examination
B. Blood glucose
C. Fecal occult blood
D. Prostate-specific antigen
Answer: A. Testicular examination
A newly licensed nurse is reporting to the charge nurse about the care she gave to a client.
She states, "The client said his leg pain was back, so I checked his medical record, and he last
received his pain med 6 hr ago. The prescription reads every 4 hours PRN for pain, so I
decided he needs it. I asked the unit nurse to observe me preparing and administering it. I
checked with the client 40 minutes later, and he said his pain is going away." The charge
nurse should inform the newly licensed nurse that she left out which of the following steps of
the nursing process?
A. Assessment
B. Planning
C. Intervention
D. Evaluation
Answer: Assessment
A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of
the following data should the charge nurse identify as objective data? (SATA)
A. RR of 22/min with even, unlabored respirations
B. The client's partner states, "He said he hurts after walking about 10 minutes."
C. Pain rating is a 3 on a scale of 0-10.
D. Skin in pink, warm, and dry
E. The AP reports the client walked with a limp
Answer: A. RR of 22/min with even, unlabored respirations
D. Skin in pink, warm, and dry
E. The AP reports the client walked with a limp
A nurse in a provider's office is preparing to assess a young adult male client's
musculoskeletal system as part of a comprehensive physical examination. Which of the
following findings should the nurse expect?
Answer: • Concave lumbar spine posteriorly
• Muscles slightly larger on his dominant side
A nurse is assessing a client's neurosensory system. To evaluate stereognosis, she should ask
the client to close his eyes and identify which of the following items?
Answer: A familiar object she places in his hand
A nurse is caring for a client who reports pain with internal rotation of her right shoulder. The
nurse should identify that this discomfort can affect the clients ability to perform which of the
following activities?
Answer: Fastening her bra being her back
A nurse is performing a neurosensory examination for a client. Which of the following
assessments should the nurse perform to test the client's balance?
Answer: • Romberg test
• Heel-to-toe walk
A nurse is collecting data from an older adult client as part of a neurosensory examination.
Which of the following findings should the nurse expect as changes associated with aging?
(SATA)
A. Slower light touch sensation
B. Some vision and hearing decline
C. Slower fine finger movement
D. Some short-term memory decline
E. Slower superficial pain sensation
Answer: B. Some vision and hearing decline
C. Slower fine finger movement
D. Some short-term memory decline
A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive
physical examination. Which of the following findings should the nurse expect?
Answer: • Capillary refill in 2 seconds
• Thick skin on the soles of the feet
• Numerous light brown macules on the face
A nurse is assessing an older adult client who has significant tenting of the skin over his
forearm. Which of the following factors should the nurse consider as a cause for this finding?
Answer: • Loss of adipose tissue
• Dehydration
• Diminished skin elasticity
A nurse is assessing post-op circulation of the lower extremities for a client who had knee
surgery. The nurse should include which of the following?
Answer: • Skin
• color
• Edema
• Skin temperature
A nurse is performing skin assessments on a group of clients. Which of the following lesions
should the nurse identify as vesicles?
Answer: Herpes simplex Varicella
A nurse is performing an integumentary assessment for a group of clients. Which of the
following findings should the nurse recognize as requiring immediate intervention?
Answer: Cyanosis
A nurse is caring for a client who recently had a CVA and has aphasia. Which of the
following interventions should the nurse use to promote communication with this client?
Answer: • Make sure only one person speaks at a time
• Allow plenty of the time for the client to respond
• Use brief sentences with simple words
A nurse is caring for a client who had an amphetamine overdose and has sensory overload.
Which of the following interventions should the nurse implement?
Answer: Provide a quiet room and limit stimulation
A nurse is caring for a client who reports difficulty hearing. Which of the following
assessment findings indicate a sensorineural hearing loss in the left ear?
Answer: • Weber test showing lateralization to the right ear
• Rinne test showing less time for air and bone conduction
A nurse is caring for a client who has several risk factors for hearing loss. Which of the
following medications, that the client currently takes, should alert the nurse to a further risk
for ototoxicity?
Answer: Furosemide Ibuprofen
A nurse is reviewing instructions with a client who has a hearing loss and has just started
wearing hearing aids. Which of the following statements should the nurse identify as an
indication that the client understands the instructions?
Answer: "I take the batteries out of my hearing aids when I take them off at night."
A nurse is providing discharge instructions to a client who has a prescription for the use of
oxygen in hishome. Which of the following should the nurse teach the client about using
oxygen safely in his home?
Answer: • Nail polish should not be used near a client who is receiving oxygen.
• A "No Smoking" sign should be placed on the front door.
• A fire extinguisher should be readily available in the home.
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 that the client who has heat stroke will have which of the following
Answer: Hypotension
A nurse educator is conducting a parenting class for new parents of infants. Which of the
following statements made by a participant indicates understanding of the instructions?
Answer: "Once my infant starts to push up, I will remove the mobile from over the crib."
A home health nurse is discussing the dangers of carbon monoxide poisoning with a client.
Which of the following information should the nurse include in her counseling?
Answer: Carbon monoxide binds with hemoglobin in the body.
A home health nurse is discussing the dangers of food poisoning with a client. Which of the
following information should the nurse including in her counseling?
Answer: • Immunocompromised individuals are at risk for complications from food
poisoning
• Clients who are especially at risk are instructed to eat or drink only pasteurized milk,
yogurt, cheese, or other dairy products.
• Handling raw and fresh food separately to avoid cross contamination may prevent food
poisoning.
A nurse is caring for multiple clients during a mass casualty event. Which of the following
clients is the priority?
Answer: A client who has partial thickness and full thickness burns to the face, neck, and
chest
A nurse educator is discussing the facility protocol in the event of a tornado with the staff.
Which of the following should the nurse include in the instructions?
Answer: • Place blankets over clients who are confined to beds
• Move beds away from the windows
• Draw shades and close drapes
An occupational health nurse is caring for an employee who was exposed to an unknown dry
chemical, resulting in a chemical burn. Which of the following interventions should the nurse
include in the plan of care?
Answer: Brush the chemical off the skin and clothing
A nurse on a med-surg unit is informed that a mass casualty event occurred in the community
and that it is necessary to discharge stable clients to make beds available for injury victims.
Which of the following clients should the nurse recommend for discharge?
Answer: A client who is scheduled for elective surgery A client who has chronic HTN and
BP 135/85 mm Hg
A nurse is caring for a client who is at high risk for aspiration. Which of the following actions
should the nurse take?
Answer: Instruct the client to tuck her chin when swallowing.
A nurse is caring for a client who is on a low-residue diet. The nurse should expect to see
which of the following foods on the client's meal tray?
Answer: Vanilla custard
A nurse in a senior center is counseling a group of older adults about their nutritional needs
and considerations. Which of the following information should the nurse include?
Answer: • Older adults are more prone to dehydration than younger adults are.
• Older adults need the same amount of most vitamins and minerals as younger adults do.
• Many older men and women need calcium supplementation.
A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via
an NG tube. Which of the following actions should the nurse complete prior to administering
the tube feeding?
Answer: • Auscultate bowel sounds
• Assist the client to an upright position
• Test the pH of gastric aspirate.
A nurse is preparing to insert an NG tube for a client who requires gastric decompression.
Which of the following actions should the nurse perform before beginning the procedure?
Answer: • Review a signal the client can use if feeling any distress.
• Lay a towel across the client's chest.
A nurse is caring for a client who will perform fecal occult blood testing at home. Which of
the following information should the nurse include when explaining the procedure to the
client?
Answer: The specimen cannot be contaminated with urine.
A nurse is talking with a client who reports constipation. When the nurse discusses dietary
changes that can help prevent constipation, which of the following foods should the nurse
recommend?
Answer: Fresh fruit and whole wheat toast
A nurse is caring for a client who has had diarrhea for the past 4 days. When assessing the
client, the nurse should expect which of the following findings?
Answer: • Hypotension
• Fever
• Poor skin turgor
A nurse is preparing to administer a cleansing enema to an adult client in preparation for a
diagnostic procedure. Which of the following are appropriate steps for the nurse to take?
Answer: • Warm the enema solution prior to instillation.
• Position the client on the left side with the right leg flexed forward.
• Lubricate the rectal tube or nozzle.
While a nurse is administering a cleansing enema, the client reports abdominal cramping.
Which of the following actions should the nurse take?
Answer: Lower the enema fluid container.
A nurse is using an interpreter to communicate with a client. Which of the following are
appropriate when communicating with a client and his family?
Answer: • Ask the family one question at a time.
• Use lay terms if possible.
• Do not interrupt the interpreter and the family as they talk.
A nurse is caring for a client who shares the same religious background. Which of the
following information should the nurse anticipate?
Answer: the same religious beliefs may influence individuals differently.
A nurse is caring for a client who is crying while reading from his devotional book. Which of
the following interventions should the nurse take?
Answer: Provide quiet times for these moments.
A nurse is planning care for a client who is a devout Muslim and is 3 days postoperative
following ahip arthroplasty. The client is scheduled for two physical therapy sessions today.
Which of the following statements by the nurse indicates culturally appropriate care to the
Muslim client?
Answer: "I will discuss the daily schedule with the client to make sure the client will have
time for prayer."
A nurse is caring for a client who is a Jehovah's Witness and is scheduled for surgery as a
result of a motor vehicle crash. The surgeon tells the client that a blood transfusion is
essential. The client tells the nurse that based on his religious values and mandates, he cannot
receive a blood transfusion. Which of the following responses by the nurse is appropriate?
Answer: "Let's discuss the necessity for a blood transfusion with your religious and spiritual
leaders and come to a reasonable solution."
A nurse in a providers office is caring for a client who states that, for the past week, she has
felt tired during the day and cannot sleep at night. Which of the following responses should
the nurse ask when collecting data about the clients difficulty sleeping?
Answer: • "Does your lack of sleep interfere with your ability to function during the day?"
• "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?"
• "Has anyone ever told you that you seem to stop breathing for a few seconds when you are
asleep?"
• "Tell me about any personal stress you are experiencing."
A nurse is talking with a client about ways to help him sleep and rest. Which of the following
recommendations should the nurse give to the client to promote sleep and rest?
Answer: • Practice muscle relaxation techniques
• Exercise each morning
• Alter the sleep environment for comfort
• Limit fluid intake to at least 2 hr before bed
A nurse is caring for an older adult client who has been following the facilities routines and
bathing in the morning. However, at home, she always takes a warm bath just before bed
time. Now she is having difficulty sleeping at night. Which of the following actions should
the nurse take first?
Answer: Allow the client to take a bath in the evening
A nurse is preparing a presentation at a local community center about sleep hygiene. When
explaining REM sleep, which of the following characteristics should the nurse include?
Answer: • REM sleep provides cognitive restoration
• It is difficult to awaken a person in REM sleep
• Vivid dreams are common during REM sleep
A nurse is instructing a client who has a new diagnosis of narcolepsy about measures that
might help with self-management. Which of the following statements should the nurse
identify as an indication that the client understands the instructions?
Answer: "I'll take a short nap whenever I feel sleepy."
A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery
bypass graft. Just as the transport team arrives, the nurse takes the client's vital signs and
notes an elevation in blood pressure and heart rate. The nurse should recognize this response
as which part of the general adaptation syndrome (GAS)?
Answer: Alarm reaction
A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of
the following nursing interventions for stress, coping, and adherence to the treatment plan
should the nurse initiate at this time?
Answer: • Allow the client to provide input in the treatment plan.
• Assist the client with time management, and address the client's priorities.
• Encourage the client in the expression of feelings and concerns.
A nurse is caring for a client who has left-sided hemiplegia resulting from a cerebrovascular
accident. The client works as a carpenter and is now experiencing a situational role change
based on physical limitations. The client is the primary wage earner in the family. Which of
the following best describes the client's role problem?
Answer: Role conflict
A nurse caring for a family who is experiencing a crisis. Which of the following approaches
should the nurse use when working with a family using an open structure for coping with
crisis?
Answer: Convening a family meeting
A nurse is caring for a client who states, "I have to check with my wife and see if she thinks I
am ready to go home." The nurse replies, "How do you feel about going home today?" Which
clarifying technique is the nurse using to enhance communication with the client?
Answer: Reflecting
Which of the following actions should the nurse take when using the communication
technique of active listening?
Answer: • Use an open posture
• Establish and maintain eye contact
• Respond positively when giving feedback
A nurse is caring for a client who is concerned about his impending discharge to home with a
new colostomy because he is an avid swimmer. Which of the following statements should the
nurse make?
Answer: • "Your daily routines will be different when you get home."
• "Tell me about your support system you'll have after you leave the hospital."
• "Let me tell you about a friend of mine with a colostomy who also enjoys swimming."
Which of the following strategies should a nurse use to establish a helping relationship with a
client?
Answer: Encourage the client to communicate his thoughts and feelings
A nurse is caring for a school-age child who is sitting in a chair. To facilitate effective
communication, which of the following actions should the nurse take?
Answer: Sit at eye level with the child
A nurse at a clinic is collecting data about pain from a client who reports severe abdominal
pain. The nurse asks the client whether or not he has nausea and has been vomiting. Which of
the following pain characteristics is the nurse attempting to determine?
Answer: Presence of associate manifestations
A nurse is collecting data from a client who is reporting pain despite taking analgesia. Which
of the following actions should the nurse take to determine the intensity of the clients pain?
Answer: Offer the client a pain scale to measure his pain
A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the
following clients should the newly licensed nurse identify as experiencing chronic pain?
Answer: A client who has episodic back pain following a fall 2 yr ago
A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the
medication. Which of the following effects should the nurse anticipate?
Answer: • Bradypnea
• Orthostatic hypotension
• Nausea
A nurse is caring for a client who is receiving morphine via PCA infusion device after
abdominal surgery. Which of the following statements indicates that the client knows how to
use the device?
Answer: • "I should tell the nurse if the pain doesn't stop while I am using the device."
A nurse is caring for a client scheduled for abdominal surgery. The client reports being
worried. Which of the following actions should the nurse take?
Answer: Offer info on a relaxation technique and ask the client if he is interested in trying it
A nurse is assessing a client as part of an admission history. The client reports drinking an
herbal tea every afternoon at work to relieve stress. The nurse should suspect the tea includes
which of the following ingredients?
Answer: Chamomile
A nurse is reviewing CAM therapies with a group of nursing students. The nurse should
classify which of the following as a mind-body therapy?
Answer: • Art therapy
• Yoga
• Biofeedback
A nurse is teaching a group of nursing students on CAM therapies they can incorporate into
their practice without the need for specialized licensing or certification. Which of the
following should the nurse encourage the students to use?
Answer: • Guided imagery
• Meditation
• Music therapy
A nurse is planning to use healing intention with a client who is recovering from a lengthy
illness. Which of the following is the priority action the nurse should take before attempting
this particular mind-body intervention?
Answer: • Ask whether the client is comfortable with using prayer
A nurse is observing a client drawing up and mixing insulin. Which of the following findings
should the nurse identify as an indication that psychomotor learning has taken place?
Answer: client is able to demonstrate appropriate technique
A nurse in a providers office is collecting data from the mother of a 12 month old infant.
Client states her son is old enough for toilet training. Following an educational session with a
nurse the client now states that she will postpone toilet training until her son is older.
Learning has occurred in which of the domains?
Answer: Affective
A nurse is providing pre-op education for a client who will undergo a mastectomy the next
day. Which of the following statements should the nurse identify as an indication that the
client is ready to learn?
Answer: Can you tell me about how long the surgery will take
A nurse is preparing an instructional session for an older adult about managing stress
incontinence. Which of the following actions should the nurse take when first meeting with
the client?
Answer: Determine what the client know about stress incontinence
A nurse is evaluating how well a client learned the info he presented in an instructional
session about following a heart-healthy diet. The client states that she understands what to do
now. Which of the following actions should the nurse take to evaluate the clients learning?
Answer: Ask client to explain how to select or prep meals
Trust vs. Mistrust
Answer: • Infancy (0-1)
• A sense of trust requires a feeling of physical comfort & minimal amount of fear about the
future.
• Infant's basic needs are met by responsive, sensitive caregivers.
• Important event: feeding
Autonomy vs. Shame and doubt
Answer: • Toddler (1-3) after gaining trust infants discover they have a will. They assert their
sense of autonomy or independence.
• If restrained or punished too harshly, they are likely to develop a sense of shame & doubt
• Important event: toilet training
Initiative vs. guilt
Answer: • Preschool (3-5) learn to initiate tasks and carry out plans or they feel guilty about
efforts to be independent
• Important event: independence
Industry vs. Inferiority
Answer: • Elementary school (6-puberty)
• Children direct their energy toward mastering knowledge & intellectual skills.
• The danger at this stage involves feeling incompetent & unproductive. Important event:
school
Identity vs. Role confusion
Answer: • Adolescence (teens-20s)
• Teenagers work at refining a sense of self by testing roles and then integrating them in form
a single identity or become confused about who they are Important event: peer relationships
Intimacy vs. Isolation
Answer: • Young adulthood (20s-early 40s)
• Young adults struggle to from close relationships and to gain the capacity for intimate love,
or they feel socially isolated Important event: love relationships
Generatively vs. Stagnation
Answer: • Middle adulthood (40s-60s)
• The middle-aged discover a sense of contributing to the world usually through family and
work, or they feel a lack of purpose Important event: parenthood
Integrity vs. despair
Answer: • Late adulthood (late 60s and up)
• When reflecting on his or her life the older adult may feel a sense of satisfaction or failure
• Important event: reflection on/acceptance of ones life
A nurse is assessing the heart sounds of a client who has developed chest pain that becomes
worse with inspiration. The nurse auscultates a high-pitched scratching sound during both
systole and diastole with the diaphragm of the stethoscope positioned at the left sternal
border. Which of the following heart sounds should the nurse document?
Answer: Pericardial friction rub
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following
action should the nurse take?
Answer: Place the bladder of the cuff over the posterior aspect of the thigh
A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly
licensed nurses. Which of the following actions should the charge nurse teach as the first
response in CPR?
Answer: Confirm unresponsiveness
A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported
for the procedure, which of the following actions should the nurse take first?
Answer: Identify the client using to identifiers
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the
following actions should the nurse take?
Answer: Administer analgesics to the child on a routine schedule throughout the day and
night
A nurse is providing teaching to a client who has heart failure about how to reduce his daily
intake of sodium. Which of the following factors is the most important in determining the
client's ability to learn new dietary habits?
Answer: The involvement of the client in planning the change
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client.
Which of the following actions by the newly licensed nurse requires intervention?
Answer: Obtaining cotton balls for the tracheostomy
A nurse is preparing to perform mouth care for an unresponsive client.Which of the following
actions should the nurse plan to take?
Answer: Raise the level of the bed
A nurse is witnessing a client sign an informed consent form for surgery. Which of the
following describes what the nurse is affirming by this action?
Answer: The signature on the pre-operative consent form is the clients
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions
should the nurse take first?
Answer: Perform hand hygiene
A nurse is caring for an older adult client who becomes agitated when the nurse requests that
the client's dentures be removed prior to surgery. Which of the following responses should the
nurse make?
Answer: What worries you about being without your teeth?
A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian
cancer. Which of the following statements by the client indicates she is experiencing
psychological distress?
Answer: I keep having nightmares about my upcoming surgery
