VATI Predicator Exam
A nurse is caring for a client who has heart failure and reports difficulty with limiting sodium in
their diet. Which of the following recommendations should the nurse provide?
Answer: Replace bottled salad dressing with homemade vinegar and oil dressing.
A nurse is contributing to the plan of care for a newborn who is experiencing heroin withdrawal.
The nurse should anticipate a prescription for which of the following medications?
Answer: Methadone
A nurse is reinforcing teaching with a group of expectant parents regarding the proper use of a
car seat. Which of the following statements by a parent indicates an understanding of the
teaching?
Answer: "I can place a rolled towel on each side of my newborn's head until he can hold his
head up."
A nurse is contributing to the discharge plans for four clients. The nurse should identify that
which of the following clients requires an interdisciplinary care conference?
Answer: A client who has hemiparesis and lives alone
A nurse is reinforcing discharge teaching with a client who has type 1 diabetes mellitus. Which
of the following client statements indicates an understanding of the teaching?
Answer: "I will dispose of insulin needles in a puncture-proof container."
A nurse is planning to reinforce teaching with a preschooler who is about to undergo an incision
and drainage for cellulitis on the left arm. Which of the following techniques should the nurse
use?
Answer: Take the child on a tour of the surgery and recovery areas.
A nurse in a paediatric clinic is reviewing the urine laboratory results for an adolescent. For
which of the following results should the nurse notify the provider?
Answer: Ketones positive
A nurse is visiting with the family of a client who has just died. Which of the following actions
should the nurse take to promote comfort for the family?
Answer: Allow the family as much time as they want with the client.
A nurse on a maternal newborn unit is assisting with the preparation of an in-service presentation
about infection control. Which of the following information should the nurse recommend to
include?
Answer: Visitors who have an upper respiratory infection should wear a mask.
A nurse is collecting data from a client who is postoperative and received hydromorphone 4 mg
PO 15 min ago. The client tells the nurse, "My pain level is still 8 on a 0 to 10 scale." Which of
the following actions should the nurse take first?
Answer: Reevaluate the client's response to the medication in 30 min.
A nurse in a provider's office is reinforcing teaching with the parents of a school-age child who
has an active case of Pediculosis humanus capitis. Which of the following should the nurse
include in the teaching?
Answer: Wash the bed linens in hot water.
A nurse from a medical-surgical unit is floating to a postpartum unit. Which of the following
clients is an appropriate assignment for the nurse to accept?
Answer: A client who had a cesarean delivery 24 hr ago
A nurse is assisting with the care of a client who is in active labor. Which of the following data is
the priority for the nurse to collect following an amniotomy?
Answer: Fetal heart rate
A nurse is assisting in the preparation of an in-service for a group of unit nurses about ethical
principles. Which of the following nursing actions should the nurse include as an example of
fidelity?
Answer: A nurse keeps a promise made to a client.
A nurse is contributing to the plan of care for a 12-month-old infant following cleft palate repair.
Which of the following actions should the nurse include?
Answer: Maintain elbow restraints on the infant.
A nurse administered an IM injection to a client. Which of the following actions should the nurse
take to reduce the risk of a needlestick injury?
Answer: Dispose of the used needle immediately in a sharps container.
A nurse is collecting data from a client who has hepatitis A. Which of the following findings
should the nurse expect Abdominal pain A nurse is reinforcing teaching with a client about
caring for a new colostomy. Which of the following statements should the nurse make?
Answer: "You should empty the colostomy bag when it is three-fourths full."
A charge nurse is explaining the role of a licensed practical nurse to an assistive personnel (AP).
Which of the following responsibilities should the charge nurse include?
Answer: Assessing a client's health status
A nurse is assisting with the admission of a client who has mononucleosis. Which of the
following isolation precautions should the nurse initiate?
Answer: Droplet
A nurse is reinforcing teaching with a client who was diagnosed with diabetes mellitus and
requires insulin injections. Which of the following client statements indicates an understanding
of the teaching?
Answer: "I should use an injection site that is 1 inch from the previous site."
A nurse is reinforcing teaching about home safety with the parent of an 8-month-old infant.
Which of the following statements by the parent indicates an understanding of the teaching?
Answer: "I will keep the door to the bathroom closed."
A nurse is collecting data from a newly admitted client. Which of the following questions should
the nurse ask to assess the client's abstract thinking ability?
Answer: "What does the phrase 'butterflies in my stomach' mean?"
A nurse is collecting health history data from a client who has hemorrhoids. Which of the
following findings should the nurse expect?
Answer: Chronic constipation
A nurse is reviewing client care assignments prior to the beginning of a shift. Which of the
following client assignments should the nurse identify as being outside the scope of practice for
an LPN?
Answer: A client who has a new onset of chest pain
A nurse is checking the home environment of a client for safety hazards. Which of the following
items require intervention by the nurse?
Answer: The television set is turned to a loud volume.
A nurse is reinforcing teaching about home care with the parents of a child who has a seizure
disorder. Which of the following instructions should the nurse include?
Answer: Call EMS if a seizure lasts 5 min or more.
A nurse is caring for a client who is asking about the technique of effleurage and its use in labor
and delivery. Which of the following responses should the nurse make regarding this technique?
Answer: "It is a light stroking of the skin during a uterine contraction."
A newly licensed nurse is having difficulty finishing client care tasks during their shift. Which of
the following techniques should the nurse plan to use to assist with time management?
Answer: Try to complete a task before moving on to the next.
A nurse is contributing to the plan of care for a client who has bulimia nervosa. Which of the
following interventions should the nurse recommend?
Answer: Observe the client for 1 hr after meals.
A nurse is collecting data from a child who has acute glomerulonephritis. Which of the following
findings should the nurse expect?
Answer: Periorbital edema
A nurse is providing preoperative teaching for an adolescent who is scheduled for a cardiac
catheterization. Which of the following instructions should the nurse include?
Answer: "You can take a shower 1 day after your procedure."
A nurse is preparing to administer 5 units of regular insulin and 20 units of NPH insulin to a
client who has type 1 diabetes mellitus. Which of the following actions should the nurse take
first?
Answer: Withdraw 5 units of regular insulin from the vial.
A nurse working at a crisis hotline call center receives a call from a client who states, "I cannot
take it. My life is over." Which of the following is the priority response by the nurse?
Answer: Are you thinking of harming yourself?"
A nurse has obtained a client's oxygen saturation measurement of 88% on 2 liters of oxygen via
nasal cannula. Which of the following actions should the nurse take?
Answer: Compare the result with the baseline reading.
A nurse is caring for a newborn following a circumcision. Which of the following manifestations
indicates the newborn is experiencing pain?
Answer: Diaphoresis, Transient strabismus
A nurse is reinforcing teaching with the parents of a preschool-age child who has a new
diagnosis of celiac disease. Which of the following foods should the nurse recommend?
Answer: corn tortillas with black beans
A nurse is preparing to instill an otic suspension into an adult client's ear. Which of the following
methods should the nurse plan to use?
Answer: Pull the auricle upward and backward.
A nurse is caring for a client who is breastfeeding their 5-day-old newborn. Which of the
following should the nurse identify as an indication that the newborn is breastfeeding
effectively?
Answer: Makes audible swallowing sounds
A nurse is assisting with the admission of an older adult client. Which of the following subjective
findings suggests that the client may have cataracts?
Answer: Cloudy vision
A nurse is collecting data from the guardian of a toddler during a well-child visit. The guardian
expresses concern to the nurse because his child has a poor appetite, but drinks a quart of milk
each day. The nurse should identify that this practice places the toddler at risk for which of the
following conditions?
Answer: Lactose intolerance
A nurse in a mental health unit asks a client who has schizophrenia, "How are you?" Which of
the following responses should the nurse identify as the speech alteration of echolalia?
Answer: "How are you?"
A nurse is reinforcing teaching with an adolescent who has a new prescription for cefazolin. For
which of the following findings should the nurse instruct the adolescent to monitor and report to
the provider?
Answer: Depression
A nurse is reinforcing teaching with a client who has a new prescription for digoxin to treat heart
failure. Which of the following should the nurse include as an expected effect of this medication?
Answer: Increased heart rate
A nurse is reinforcing teaching with a school-age child who has hemophilia about participating in
school sports. Which of the following sports should the nurse recommend for the child? (Select
all that apply.)
Answer: Golf, Swimming
A nurse is caring for a client who attempted suicide. Which of the following actions should the
nurse take?
Answer: Serve meals with plastic utensils.
A nurse is preparing a client's insulin regimen. Which of the following insulins can be mixed?
(Select all that apply.)
Answer: Insulin aspart, Regular insulin, Insulin lispro
A nurse in a long-term care facility has received change-of-shift report about four clients. Which
of the following clients should the nurse attend to first?
Answer: A client who has COPD and dementia and was agitated during the night shift
A nurse is caring for a client who has a new colostomy. The client tells the nurse, "I don't want
anyone to see me with this bag." Which of the following responses should the nurse make?
Answer: "Why don't you want people to see the colostomy bag?"
A nurse is reinforcing teaching with a client who has a permanent pacemaker in place. Which of
the following statements by the client indicates an understanding of the teaching?
Answer: "I will remove my microwave oven from my home."
A nurse is caring for a client who is receiving prazosin. The client's blood pressure is 100/60 mm
Hg. Which of the following actions should the nurse take?
Answer: Instruct the client to stand up slowly.
A nurse is collecting data from a client who is taking heparin to prevent deep-vein thrombosis
and has bloody stools. Which of the following laboratory values should the nurse report to the
provider?
Answer: INR 5.2
A nurse is collecting data from a client who has a long-leg cast on his left leg and reports severe
pain. Which of the following findings should the nurse identify as an indication that the client
might have compartment syndrome? (Select all that apply.)
Answer: Pallor in the exposed portion of the left foot, Inability to move the left foot, Paresthesia
in the left foot
A nurse is providing change-of-shift report for a client who has heart failure. Which of the
following information should the nurse include in the report?
Answer: The client's most recent blood pressure reading was 110/60 mm Hg. The client has +2
pitting edema in the lower extremities.
A nurse is reinforcing teaching with a newly licensed nurse about the HIPAA Privacy Rule.
Which of the following statements by the newly licensed nurse indicates an understanding of the
teaching?
Answer: "A client has the right to view their medical record."
A nurse is reinforcing teaching with a client who plans to bottle feed her newborn. Which of the
following statements indicates an understanding of the instructions?
Answer: "I will feed my baby six to eight times a day."
A nurse is caring for a female client who has a new diagnosis of breast cancer. The client is
concerned about potential changes to her body image depending on her choice of treatment.
Which of the following actions should the nurse take?
Answer: Initiate a client referral to Reach to Recovery.
A nurse is caring for a client who has COPD. The nurse should identify that which of the
following findings is the priority to report?
Answer: Hgb 20 g/dL
A nurse is reinforcing discharge teaching with a client who had an above-the-knee amputation
and has a prosthesis. Which of the following instructions should the nurse include?
Answer: Clean the prosthesis using a damp, soapy cloth.
A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube.
Which of the following actions should the nurse take?
Answer: Perform oral care every 2 hr.
A charge nurse in a long-term care unit is planning care for a group of clients. Which of the
following care tasks should the nurse plan to delegate to an assistive personnel?
Answer: Measuring urine output every 2 hr for a client recently diagnosed with a urinary tract
infection
A nurse is preparing to remove a peripheral IV for a preschooler. In which order should the nurse
complete the following steps? (Move the steps into the box on the right, placing them in the
order of performance. Use all the steps.)
Answer: The Correct order is Turn off the IV infusion pump and clamp the IV tubing. Allow the
preschooler to assist with removing the transparent dressing over the IV. Remove the IV catheter
while keeping the catheter hub parallel to the insertion site. Inspect the IV catheter tip. Apply
firm pressure at the IV site.
A nurse is assisting with developing a discharge plan for a client who has a new diagnosis of
diabetes mellitus. The client is independent and lives alone. Which of the following interventions
should the nurse plan to include?
Answer: Refer the client to a diabetic support group.
A nurse is reinforcing teaching with a client who is at 35 weeks of gestation and has a
prescription for a lecithin/sphingomyelin ratio. Which of the following statements should the
nurse make?
Answer: "This test will determine fetal lung maturity."
A nurse is caring for a client who has schizophrenia. The client tells the nurse, "Government
agents are out to get me." Which of the following responses should the nurse make?
Answer: "It must be frightening to believe that someone is after you."
A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client. The
nurse should identify that which of the following actions by the AP indicates an understanding of
the procedure?
Answer: Elevates the client's legs before applying the stockings
A nurse is caring for a client who is in mechanical restraints after becoming violent with a staff
member. Which of the following actions should the nurse take?
Answer: Request that the provider write an as-needed prescription for restraints.
A nurse is caring for a client who had a transurethral resection of the prostate and now is
receiving continuous bladder irrigation. Which of the following actions should the nurse take?
(Select all that apply.)
Answer: Document urine color. Monitor the client for reports of bladder spasms. Check the
drainage tubing for obstructions.
A nurse is reinforcing teaching with the parent of an infant who is receiving furosemide. The
nurse should reinforce with the parent that which of the following laboratory tests will be
monitored while the infant is receiving this medication?
Answer: Potassium
A nurse is caring for a client who is using a non-rebreather mask for oxygen delivery. The nurse
should identify which of the following as an indication that the equipment is functioning
properly?
Answer: The attached reservoir bag is inflated.
A nurse is contributing to the plan of care for a school-age child who has sickle-cell disease and
is experiencing a vaso-occlusive crisis. Which of the following should the nurse recommend to
include in the plan of care?
Answer: Perform passive range-of-motion exercises.
A nurse is admitting a client who is scheduled for an elective surgery. Which of the following
actions should the nurse take to verify the status of the client's advance directives?
Answer: Ask the client whether they have advance directives.
A nurse is preparing to administer cefaclor to a preschooler who weighs 20 kg. The child is to
receive cefaclor 30 mg/kg/day to divide equally every 8 hr. Available is cefaclor suspension 125
mg/5 mL. How many mL should the nurse administer for one dose?
Answer: 8 mL
A nurse is reinforcing teaching about complete and incomplete proteins with a client who has a
prescription for a high-protein diet. The nurse should identify which of the following foods as
sources of complete proteins? (Select all that apply.)
Answer: Salmon, Hard-boiled eggs, Cottage cheese
A nurse in an urgent care clinic is collecting data from a client who reports having diarrhea for
the past 3 days. Which of the following findings indicates hypokalemia?
Answer: Muscle weakness
A nurse is caring for a client who is postoperative following a hemicolectomy. Which of the
following is a subjective indication that the client needs PRN pain medication?
Answer: The client reports pain.
A nurse is collecting data from a client who has a gastrostomy tube and is experiencing diarrhea.
Which of the following factors should the nurse identify as a potential cause of the diarrhea?
Answer: The formula was given immediately following removal from the refrigerator.
A nurse is caring for an adolescent who has an allergy to penicillin. Which of the following
prescriptions should the nurse clarify with the provider?
Answer: Cefazolin
A nurse is collecting data from a client who is 1 day postoperative following a total hip
arthroplasty and has deep-vein thrombosis. Which of the following findings should the nurse
expect in the affected extremity?
Answer: Dull, aching pain
A nurse is caring for an infant who is drinking a cow's milk formula and has bloody stools.
Which of the following recommendations should the nurse make to the infant's guardian?
Answer: Switch to a soy-based formula.
A nurse is reinforcing discharge teaching with an older adult client who has osteoarthritis. Which
of the following statements by the 52A6658V49client indicates an understanding of the
teaching?
Answer: "I will limit purine intake in my diet."
A nurse is preparing to administer required immunizations to a toddler during a well-child visit.
The parent asks the nurse how many baby aspirins he should administer if the toddler develops a
fever. Which of the following responses should the nurse make?
Answer: You should follow the label directions based on your child's weight."
A nurse is assisting with the admission of an older adult client who has impaired mobility and is
at risk for falls. Which of the following actions should the nurse plan to perform first?
Answer: Check the client's ability to use the call light.
A nurse is reinforcing teaching about a safety plan for a client who reports partner violence.
Which of the following instructions should the nurse include?
Answer: "Keep a packed bag by your front door."
A nurse is reinforcing teaching with the parents of a newborn who had a circumcision. Which of
the following client statements indicates understanding of the teaching?
Answer: "I will apply petroleum jelly to the penis with each diaper change."
A nurse is collecting data from a client who has asthma. Which of the following prescribed
medications should the nurse administer first for severe wheezing?
Answer: Bronchodilators
A nurse is reinforcing teaching with the parent of a newborn about security procedures. Which of
the following instructions should the nurse include?
Answer: "You should verify the identity of anyone who wants to remove your baby from the
room.
A nurse is reinforcing discharge teaching about limiting sodium intake with a client who has a
new diagnosis of cardiomyopathy. Which of the following client responses indicates an
understanding of the teaching?
Answer: "I can have a frozen juice bar for dessert."
A nurse is preparing to administer a liquid medication to a 6-month-old infant who is crying.
Which of the following actions should the nurse take to reduce the risk of aspiration?
Answer: Administer using a needleless syringe in the buccal cavity.
A charge nurse is supervising a newly licensed nurse who is caring for a client who is
experiencing auditory hallucinations and is refusing medication. The newly licensed nurse
suggests placing the medication in the client's food to the charge nurse. Which of the following
actions should the charge nurse take?
Answer: Remind the newly licensed nurse that the client has a right to refuse medication.
After receiving change-of-shift report, which of the following clients should the nurse collect
data from first?
Answer: A client who has heart failure and reports severe dyspnea
A nurse is reinforcing teaching about safety with the parent of a newborn. Which of the
following instructions should the nurse include?
Answer: Take the newborn to the nursery before showering.
A nurse is reinforcing teaching about epidural PCA with a client who is in active labor. Which of
the following statements should the nurse include?
Answer: "The machine is programmed to prevent you from administering more than a safe
dose."
A nurse working on a mental health unit is meeting with a client who has been on the unit for 2
days. The nurse greets the client and asks, "What has been happening with you today?" Which of
the following therapeutic techniques is the nurse using?
Answer: Focusing
A nurse is reinforcing teaching with a client who is 12 hr postpartum and has an episiotomy.
Which of the following instructions should the nurse include?
Answer: Change the perineal pad with each void.
A nurse is caring for an older adult client who states, "I can't pay for my care because my kid
took all my money." Which of the following actions should the nurse take?
Answer: Report the possible abuse to adult protective services.
A nurse is caring for a client who is scheduled for open heart surgery. The client states, "I am
confident I will be able to go home a few hours after the surgery." The nurse should identify that
the client is experiencing which of the following stages of grief?
Answer: Denial
A nurse is reinforcing teaching about self-administration of nasal drops with a client. Which of
the following positions should the nurse recommend for instillation of the drops?
Answer: Orthopneic
A nurse is reinforcing teaching with a client about smoking cessation. Which of the following
client statements indicates an understanding of the teaching?
Answer: "I should join a support group to help me be successful."
A nurse is reviewing the medication record of a client who has a new prescription for fluoxetine.
Which of the following medications should the nurse expect the provider to discontinue 2 weeks
before starting fluoxetine treatment?
Answer: Phenelzine
A nurse is caring for a client who has viral pneumonia. Which of the following actions should the
nurse take?
Answer: Administer azithromycin.
A nurse is contributing to the plan of care for a client who has Parkinson's disease. Which of the
following interventions should the nurse plan to include?
Answer: Keep suction equipment at the client's bedside.
A nurse is reinforcing teaching with the guardian of a preschooler who has a new diagnosis of
enterobiasis. Which of the following information should the nurse include in the teaching?
Answer: "Everyone who lives in the home will need medication." "Wash all clothes and bed
linens in cold water."
A nurse is reinforcing teaching about confidentiality with a client. Which of the following
statements should the nurse include in the teaching?
Answer: "Only health care staff providing care will see your medical record."
A nurse is caring for a client who is participating in a therapy session for anger management. The
client states that their recent behavior is due to the loss of their job. The nurse should identify
that the client is using which of the following defense mechanisms?
Answer: Rationalization
A nurse is caring for a client who has a cast on their left lower leg. Which of the following
actions should the nurse take?
Answer: Avoid elevating the extremity when the client is resting in bed.
A nurse is reinforcing teaching with a parent about appropriate snacks for a toddler. Which of the
following foods should the nurse include?
Answer: Graham crackers
A nurse is caring for a client who has bipolar disorder and is experiencing mania. Which of the
following actions should the nurse take?
Answer: Frequently remind the client of the expectations for her behavior.
A nurse is preparing to admit a client who has bacterial meningitis. Which of the following items
should the nurse place in the client's room?
Answer: Seizure pads
A nurse is caring for a client who was recently admitted to an inpatient mental health unit. The
client tells the nurse that he is not coming out of his room anymore because other clients on the
unit make fun of him. Which of the following responses by the nurse is appropriate?
Answer: "You feel upset by the responses of others."
A nurse is reinforcing dietary teaching with an adolescent who is at 10 weeks of gestation. Which
of the following statements should the nurse make?
Answer: "You should consume 1,300 milligrams of calcium each day."
A client who has inoperable cancer tells the nurse that she does not want to pursue the
recommended treatment. She asks if the provider can force her to have the treatment. Which of
the following is an appropriate response by the nurse?
Answer: You have the right to refuse the recommended treatment plan."
A nurse is expressing concern about his assignment with the charge nurse. The nurse states that
he has more work to do than anyone else. Which of the following statements by the charge nurse
demonstrates the conflict resolution strategy of competing?
Answer: "We will take a look at the assignments together and attempt to modify the workload
you are concerned about."
A nurse in the newborn nursery is collecting data about a newborn's Moro reflex. Which of the
following actions should the nurse take to elicit this reflex?
Answer: Clap hands after laying the newborn on a flat surface.
A nurse is reviewing the medical record for a client who is at 38 weeks of gestation, tested
positive for group B streptococcus ß-hemolytic, and is allergic to penicillin. The nurse should
identify that which of the following medications is contraindicated for this client?
Answer: Ampicillin
A nurse is caring for a client who is receiving total parenteral nutrition. Which of the following
laboratory results indicates a possible complication of this therapy?
Answer: Serum calcium 12.5 mg/dL
A nurse is assisting with triaging clients in a mass casualty situation. The nurse should
recommend that which of the following clients receive care first?
Answer: A client who has diminished breath sounds and paradoxical chest movement
A nurse in an acute mental health facility observes a client having a panic attack. Which of the
following interventions should the nurse implement first?
Answer: Instruct the client to use abdominal breathing.
A nurse is collecting a sputum specimen from a client for culture and sensitivity. Which of the
following actions should the nurse take?
Answer: Refrigerate the specimen until the time of transport to the laboratory.
A nurse is contributing to the plan of care for a client who has bipolar disorder and is
experiencing mania. Which of the following actions should the nurse include in the plan of care?
Answer: Decrease the level of environmental stimuli.
A nurse is preparing to insert a nasogastric tube for a client who has a prescription for gastric
decompression. Which of the following supplies should the nurse obtain prior to the procedure?
Answer: pH strips
A nurse is assisting in the development of an in-service for staff members about physical abuse
of children. Which of the following children are at an increased risk for physical abuse?
Answer: Children who were born after 38 weeks of gestation
A nurse is collecting data from a 3-month-old infant who is 6 hr postoperative following a cleft
palate repair. Which of the following pain rating tools should the nurse use?
Answer: FLACC scale
A nurse is caring for a child who has terminal cancer. Which of the following responses by the
child's siblings should the nurse expect?
Answer: The school-age sister is concerned about the impact of her sibling's death on herself
A nurse is reinforcing teaching with an older adult client about physical changes that occur with
aging. Which of the following should the nurse include as an expected age-related change?
Answer: Increased joint stiffness due to loss of elasticity in joint cartilage.
A nurse is assisting with the plan of care for a client who has Alzheimer's disease. Which of the
following actions should the nurse recommend for the plan of care?
Answer: Give directions using simple phrases.
A nurse is assisting with the care of an adolescent who is scheduled for surgery. Which of the
following actions should the nurse plan to take?
Answer: Provide a tour of the perioperative area prior to surgery.
A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty.
The nurse is preparing to change the client's surgical dressing. Which of the following actions
should the nurse take to demonstrate sensitivity to age-related changes?
Answer: Use paper tape for securing the new dressing.
A nurse is reinforcing teaching with a client who is about to undergo an upper gastrointestinal
series with fluoroscopy. Which of the following information should the nurse provide?
Answer: "You will receive an injection of contrast dye during the test."
A nurse is reinforcing teaching with a postpartum client about bathing her newborn. Which of the
following statements should the nurse include?
Answer: "Wash your newborn's head under a stream of running water."
A nurse receives report on four clients. The nurse should first collect data about the client who
has which of the following?
Answer: A decreased level of consciousness and vomiting
A nurse on a mental health unit is discussing client rights with a group of coworkers. Which of
the following statements should the nurse include?
Answer: "A client must withdraw consent for treatment in writing if he is competent to do so."
A nurse in a prenatal clinic is reinforcing teaching with a client about a nonstress test. Which of
the following statements should the nurse include?
Answer: "You will be asked to press a button when you feel your baby move."
A nurse is preparing to administer medication to a child through an enteral tube. Which of the
following actions should the nurse take after administering the medication?
Answer: Flush the tubing.
A nurse is reinforcing teaching with a client who has a new diagnosis of myasthenia gravis (MG)
and a prescription for neostigmine. Which of the following information should the nurse include
about the action of the medication?
Answer: Improves muscle strength
A nurse in a clinic is reinforcing teaching with a client who has a new prescription for a
combination contraceptive transdermal patch. Which of the following should the nurse include in
the teaching?
Answer: "Apply the patch to the lower abdomen."
A nurse is reviewing the laboratory results of a client who has DKA. The client's ABG results are
pH 7.30, PaCO2 34 mm Hg, and HCO3- 21 mEq/L. The nurse should identify that these values
indicate which of the following acid-base imbalances?
Answer: Metabolic acidosis
A nurse and an assistive personnel (AP) are caring for a client who requests a PRN pain
medication. After the nurse administers the medication, which of the following tasks should the
nurse assign to the AP?
Answer: Document the client's respiratory rate in 1 hr.
A nurse is collecting data from a client who is 24 hr postoperative following a total knee
arthroplasty. Which of the following findings on the operative leg should the nurse identify as a
manifestation of a deep-vein thrombosis?
Answer: Increase in calf size
A nurse is reviewing the medical record of a client who has sustained a full-thickness burn and is
in the emergent phase of the burn. Which of the following findings should the nurse expect?
Answer: Hypercalcemia
A nurse is caring for several clients who are receiving well-child check-ups. The nurse should
identify that the initial diphtheria, tetanus, and pertussis (DTaP) vaccine is indicated for which of
the following clients?
Answer: A 6-month-old infant
A nurse is caring for a client who has a chronic illness. In which phase of the therapeutic
relationship should the nurse help the client develop problem-solving skills?
Answer: Working phase
A nurse is reinforcing discharge teaching with the guardian of a client who is neutropenic. Which
of the following instructions should the nurse include?
Answer: "You should notify your provider if your child has a fever."
A nurse is collecting data on a client who has swelling of the lower leg. The nurse should
identify that which of the following findings is a manifestation of compartment syndrome?
Answer: Affected extremity warm to touch
A nurse is collecting data from a client who received IV morphine for postoperative pain. The
nurse should identify that which of the following findings indicates a therapeutic response to the
medication?
Answer: The client's blood pressure has been reduced.
A nurse is reinforcing discharge teaching with a client who is postoperative following laser
surgery for open-angle glaucoma. Which of the following statements by the client indicates an
understanding of the instructions?
Answer: "I will take a stool softener to prevent constipation."
A nurse is preparing to administer medication to a newborn. Which of the following information
should the nurse use to identify the newborn?
Answer: Footprints and identification number
A nurse is caring for a client who is near death. Which of the following actions should the nurse
take?
Answer: Administer scheduled pain medications.
A nurse is establishing a baseline postoperative assessment for a client who is recovering from a
right femoropopliteal bypass graft. Which of the following findings in the assessment of the
client's right leg should be of the most concern to the nurse?
Answer: The client's pedal pulse in the right foot is not palpable.
A nurse is caring for a client who is newly diagnosed with type 1 diabetes mellitus. The nurse
should recognize that the client needs a referral for diabetic education when the client does
which of the following?
Answer: States that he will treat hypoglycemic reactions with 15 g of carbohydrates
A nurse is caring for a client who has been placed on contact isolation precautions. Which of the
following interventions should the nurse implement?
Answer: Leave all equipment that is used routinely in the client's room.
A nurse is collecting data from a client whose Hgb is 8.8 mg/dL. Which of the following
statements should the nurse expect?
Answer: "I feel tired all the time."
A nurse is collecting data from a newborn who has shoulder dystocia. The nurse should identify
which of the following findings as an indication of pain?
Answer: Stiff posture
A nurse is assisting with an admission interview for a client who has schizophrenia. He tells the
nurse that he is receiving special audible messages from the Central Intelligence Agency that no
one else is able to hear. The nurse should identify that the client is having which of the following
alterations in perception?
Answer: Hallucination
A nurse is reinforcing teaching with a client who is about to undergo a thoracentesis. Which of
the following statements by the client indicates an understanding of the information?
Answer: "I will have a chest x-ray following the procedure."
A nurse is setting up a sterile field prior to performing a dressing change. Which of the following
actions should the nurse take?
Answer: Pour liquids from 10 to 15 cm (4 to 6 in) above the sterile field.
A nurse is collecting data from a client who has substance use disorder and reports recently
taking opioids. Which of the following findings should the nurse identify as a manifestation of
opioid intoxication?
Answer: Pinpoint pupils
A nurse is caring for a client who has major depressive disorder and is refusing their medication.
The client's family suggests placing the client's medication in their food. Which of the following
actions should the nurse take?
Answer: Inform the family that the client has the right to not take the medication
A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the
following actions by the nurse demonstrates cost-effective care?
Answer: Applies a sequential compression device to the client's lower extremities
A nurse is reviewing the medical record of a client who is requesting an oral contraceptive.
Which of the following findings should the nurse identify as a contraindication to the use of oral
contraceptives?
Answer: History of renal calculi
A nurse is reinforcing teaching with a client who has rheumatoid arthritis and is using a straightlegged cane for ambulation. Which of the following instructions should the nurse include?
Answer: "Keep the cane on the stronger side of the body."
A nurse is collecting data from a client who has preeclampsia and is receiving magnesium sulfate
via a continuous IV infusion. Which of the following findings should the nurse report to the
provider?
Answer: Urine output 20 mL/hr
A nurse in a provider's office is collecting data from a client who was discharged from the
facility 7 days ago following treatment for a deep-vein thrombosis. Which of the following
findings is the nurse's priority?
Answer: The client takes ibuprofen daily to treat musculoskeletal pain.
A nurse is caring for a client who has a new prescription for furosemide and asks the nurse about
the purpose of the medication. The nurse states, "This medication is a diuretic that removes
excess fluid from your body." Which of the following ethical concepts is the nurse exhibiting?
Answer: Veracity
A nurse is planning to administer an ophthalmic medication to a client. Which of the following
actions will minimize systemic absorption of the medication?
Answer: Wait 5 min after instillation before instilling the drops in the other eye.
A nurse is assisting with planning care for a group of clients. Which of the following tasks
should the nurse delegate to an assistive personnel?
Answer: Administering a large-volume enema to a client
A nurse is caring for a school-age child whose family adheres to a vegan diet in the home. The
nurse should recognize the child is at risk for deficiency of which of the following?
Answer: Vitamin D
A nurse is reinforcing teaching with a client diagnosed with osteoarthritis who reports joint pain,
swelling, and stiffness. Which of the following client statements indicates understanding of the
teaching?
Answer: "I will exercise my joints as much as I can when they are inflamed."
A nurse is assisting with planning care for a newly admitted client who has anorexia nervosa.
Which of the following interventions should the nurse recommend to include in the plan of care?
Answer: Weigh the client each morning after voiding.
A nurse is assisting in the care of a client who is experiencing a postpartum hemorrhage. Which
of the following medications should the nurse plan to administer?
Answer: Methylergonovine
A nurse is reviewing the laboratory results for a client who is at 32 weeks of gestation. For which
of the following results should the nurse notify the provider?
Answer: Platelet count 90,000/mm3
A nurse is caring for a client who is receiving IV fluids. The nurse realizes that the incorrect IV
solution is infusing. Which of the following actions should the nurse take?
Answer: Remove the IV catheter.
A nurse is receiving change-of-shift report on a group of clients. Which of the following clients
should the nurse see first?
Answer: A client who is exhibiting flight of ideas
A nurse is planning to obtain blood from a newborn via a heel stick. Which of the following
actions should the nurse take?
Answer: Apply a heat pack 5 to 10 min prior to the procedure.
A nurse is providing postmortem care for a client prior to the family viewing the body. Which of
the following actions should the nurse take?
Answer: Apply surgical tape to the client's eyes.
A nurse is collecting data for a client following electroconvulsive therapy. Which of the
following adverse effects should the nurse expect?
Answer: Confusion
A nurse is preparing a client who has a small bowel obstruction for insertion of a nasogastric
tube. Which of the following equipment should the nurse gather prior to the procedure?
Answer: Suction device
A nurse is admitting a client who has active tuberculosis. Which of the following nursing
interventions is appropriate?
Answer: Place the client in a room that is ventilated to the outside.
