ATI RN Comprehensive Capstone Exam With Answers-133 Solved Questions

1. A nurse is updating a plan of care after an evaluation of a client who has dysphagia. Which of
the following interventions should the nurse include in the plan?
a) Ask the client to tilt their head back when swallowing.
b) Have the client sit upright for 1 hr. following meals.
c) Administer liquids to the client using a syringe.
d) Allow the client to rest for 10 min prior to eating.
Answer: b) Have the client sit upright for 1 hr. following meals.
Rationale:
Having the client sit upright for 1 hour following meals helps to reduce the risk of aspiration.
This position allows gravity to aid in the movement of food and liquids, decreasing the
likelihood of them entering the airway.
2. A nurse is assessing the IV infusion site of a client who reports pain at the site. The site is red,
and there is warmth along the course of the vein. Which of the following actions should the
nurse take?
a) Initiate a new IV line below the original insertion site.
b) Discontinue the infusion.
c) Raise the head of the bed.
d) Obtain a culture from the area of the insertion site.
Answer: b) Discontinue the infusion.
Rationale:
The client's symptoms of pain, redness, and warmth along the vein suggest phlebitis, which is
inflammation of the vein. Discontinuing the infusion at this site is necessary to prevent further
complications such as infection or thrombosis.
3. A nurse is preparing to perform a routine abdominal assessment for a client. Which of the
following actions should the nurse take?
a) Document shiny, taut skin as an expected finding.
b) Perform palpation after auscultation.
c) Listen for 1 min before documenting absent bowel sounds.
d) Perform auscultation immediately after the client has consumed a meal.

Answer: b) Perform palpation after auscultation.
Rationale:
Performing palpation after auscultation is the correct sequence for an abdominal assessment.
Palpation before auscultation can alter bowel sounds, and palpating a tender area can lead to
guarding, making it difficult to accurately assess bowel sounds.
4. A nurse is discussing immunity with a client who has received an immunization. The nurse
should identify that an immunization functions as a part of which of the following types of
immunity?
a) Passive immunity
b) Active immunity
c) Cellular immunity
d) Acquired immunity
Answer: d) Acquired immunity
Rationale:
Acquired immunity refers to immunity that the body develops after exposure to a pathogen or
through vaccination. Immunizations stimulate the immune system to produce antibodies against
specific pathogens, providing protection against future infections.
5. A nurse is reviewing the medical records of a group of older adult clients. The nurse should
identify that which of the following is a risk factor that places older clients at an increased risk
for developing infections?
a) Overproduction of lymphocytes
b) Elevated albumin levels
c) Lowered immune system function
d) Increased body fat
Answer: c) Lowered immune system function
Rationale:
As individuals age, the immune system undergoes changes that can result in a decline in immune
function. This can include a decrease in the production of immune cells and antibodies, as well

as changes in the function of existing immune cells. These changes can increase the risk of
infections in older adults.
6. A nurse is teaching a client who has asthma the use of a metered dose inhaler. Which of the
following instructions should the nurse include in the teaching?
a) Hold your breath for 6 seconds after inhaling the medication.
b) Inhale the medication deeply for 5 seconds.
c) Do not shake the medication in the inhaler.
d) Hold the inhaler 3 inches away from your mouth.
Answer: b) Inhale the medication deeply for 5 seconds.
Rationale:
Instructing the client to inhale the medication deeply for 5 seconds ensures that the medication
reaches the lower airways where it can be more effective in treating asthma symptoms.
7. A nurse is performing a focused assessment on a client who has a history of COPD and is
experiencing dyspnea. Which of the following findings should the nurse expect?
a) Pulse oximetry reading of 95%
b) Decreased depth of respirations
c) Flaring of the nostrils
d) Respiratory rate of 16/min
Answer: c) Flaring of the nostrils
Rationale:
Flaring of the nostrils is a common sign of respiratory distress and can indicate that the client is
having difficulty breathing. It is a compensatory mechanism that helps to open the airways and
improve airflow.
8. A nurse is teaching a client about the correct use of a cane. Which of the following instructions
should the nurse include in the teaching? (Selected all that apply)
a) Ensure the cane has a rubber cap.
b) Hold the cane on the weaker side.
c) Flex the elbow slightly when using the cane.

d) Move the cane and stronger leg forward simultaneously
e) Use a quad cane for increased support.
Answer: a) Ensure the cane has a rubber cap.
c) Flex the elbow slightly when using the cane.
e) Use a quad cane for increased support.
Rationale:
Ensuring the cane has a rubber cap helps to prevent slipping. Flexing the elbow slightly when
using the cane reduces strain on the arm. Using a quad cane provides increased support and
stability, especially for clients who need more assistance with balance.
9. A nurse is teaching a group of assistive personnel about the expected integumentary changes
in older adult clients. Which of the following findings should the nurse include in the teaching?
a) Increase in subcutaneous tissue
b) Decrease in pigmentation
c) Increase in moisture levels
d) Decrease in elasticity
Answer: d) Decrease in elasticity
Rationale:
Older adult clients often experience a decrease in skin elasticity, which can lead to wrinkles and
sagging skin. This is due to a decrease in collagen and elastin production in the skin.
10. A nurse is providing teaching about measures to promote sleep with a client who has
insomnia. Which of the following client statements indicates an understanding of the teaching?
a) “I can exercise as late as 2 hours before bedtime.”
b) “I should reduce my fluid intake 2 hours before bedtime.”
c) “I should take a 1-hour nap each day.”
d) “I can eat a large meal as late as 1 hour before bedtime.”
Answer: b) “I should reduce my fluid intake 2 hours before bedtime.”
Rationale:
Reducing fluid intake before bedtime can help prevent waking up to use the bathroom during the
night, which can disrupt sleep for individuals with insomnia.

11. A nurse is assessing the pain level of a client who has dementia and difficulty
communicating. Which of the following pain assessment techniques should the nurse use?
a) Numerical pain scale
b) Verbal description
c) Faces pain scale
d) Behavioral indicators
Answer: d) Behavioral indicators
Rationale:
Since the client has difficulty communicating verbally, assessing for behavioral indicators of
pain, such as grimacing, guarding, or agitation, is more appropriate than using verbal or
numerical scales.
12. A nurse in an emergency department is monitoring the hydration status of a client who is
receiving oral rehydration. Which of the following findings should the nurse identify as requiring
further interventions?
a) Heart rate 120/min
b) BP 121/74 mm Hg
c) Temperature 37.78°C (100°F)
d) Urine specific gravity 1.020
Answer: a) Heart rate 120/min
Rationale:
A heart rate of 120/min may indicate dehydration or other fluid volume deficits, requiring further
assessment and possible intervention.
13. A nurse in a provider’s office is assessing the motor skill development of a 15-month-old
toddler during a well-child visit. Which of the following gross motor skills should the nurse
expect?
a) Takes several steps on tiptoes
b) Walks without assistance using a wide stance
c) Has an accentuated cervical curvature when standing

d) Stands with the feet turned slightly inward
Answer: b) Walks without assistance using a wide stance
Rationale:
By 15 months, most toddlers can walk independently, although their gait may still be unsteady.
They typically walk with a wide stance to maintain balance.
14. A nurse is teaching a group of parents and guardians about safety risks for adolescents.
Which of the following statements should the nurse include in the teaching?
a) “Exploring the environment commonly leads to injuries for this age group.”
b) “Most injuries sustained during this time of life are caused by developing motor skills.”
c) “At this age, peer influence to participate in high-risk behaviors can lead to injury.”
d) “The risk for injuries sustained during this age is often a result of changes in cognitive
function.”
Answer: c) “At this age, peer influence to participate in high-risk behaviors can lead to injury.”
Rationale:
Adolescents are often influenced by their peers to engage in risky behaviors, such as substance
abuse or reckless driving, which can lead to injuries.
15. A nurse is caring for a client who expresses anxiety about an upcoming surgery. Which of the
following actions should the nurse take?
a) Ask the client to describe their feelings
b) Discuss the competency of the surgeon with the client
c) Inform the client that others have had the procedure without problems.
d) Ask the client why they are experiencing anxiety.
Answer: a) Ask the client to describe their feelings
Rationale:
Asking the client to describe their feelings allows them to express their concerns and helps the
nurse better understand the source of their anxiety.
16. A nurse is reviewing information about advance directives with a newly admitted client.
Which of the following statements by the client indicates an understanding of the teaching?

a) “I need to have an attorney sign my advance directives.”
b) “I have a living will that outlines my wishes if I am unable to make decisions.”
c) “I must have a family member appointed to make my health care decisions.”
d) “I will need to sign a document stating that I want to be resuscitated if I require CPR.”
Answer: b) “I have a living will that outlines my wishes if I am unable to make decisions.”
Rationale:
A living will is a type of advance directive that outlines a person's preferences for medical
treatment if they are unable to make decisions. It does not require an attorney's signature but
should be witnessed according to state laws.
17. A nurse is planning a community education program about colorectal cancer. Which of the
following risk factors should the nurse identify as modifiable? (Select all that apply)
a) Smoking
b) Alcohol consumption
c) Inflammatory bowel disease
d) High-fat diet
e) Colorectal polyps
Answer: a) Smoking
b) Alcohol consumption
e) Colorectal polyps
Rationale:
Smoking, alcohol consumption, and the presence of colorectal polyps are modifiable risk factors
for colorectal cancer, meaning that lifestyle changes or medical interventions can reduce these
risks.
18. A nurse is reviewing the laboratory report of a client who has been experiencing a fever for
the last 3 days. Which of the following laboratory results indicates the client is experiencing
fluid volume deficit?
a) Decreased blood urea nitrogen (BUN)
b) Increased hematocrit
c) Decreased urine specific gravity

d) Increased calcium level
Answer: b) Increased hematocrit
Rationale:
An increased hematocrit can indicate dehydration or fluid volume deficit. When the body is
dehydrated, the blood becomes more concentrated, leading to an increase in hematocrit levels.
19. A charge nurse discovered that a nurse did not notify the provider that a client’s condition
had changed. The charge nurse should identify that the nurse is accountable for which of the
following torts?
a) Negligence
b) Slander
c) Invasion of privacy
d) Libel
Answer: a) Negligence
Rationale:
Negligence occurs when a nurse fails to provide the care that a reasonably prudent nurse would
provide in the same or similar circumstances, resulting in harm to the patient.
20. A nurse is performing a cultural assessment of a group of clients to maintain respect for their
value systems and beliefs. Which of the following should the nurse identify as examples of
cultural variables? (Select all that apply).
a) Eye contact
b) Personal space
c) Level of education
d) Touch
e) Blood Type
Answer: a) Eye contact
b) Personal space
d) Touch
Rationale:

Cultural variables are aspects of culture that influence communication and behavior, such as eye
contact, personal space, and attitudes toward touch. Level of education and blood type are not
typically considered cultural variables.
21. A nurse is admitting a client who has recently developed fever, confusion, and a decreased
level of consciousness. Which of the following actions should the nurse take first after obtaining
the client’s history and assessment?
a) Insert an intravenous catheter to begin fluid therapy
b) Develop actions to address the client’s manifestations
c) Identify the client’s needs
d) Determine the effectiveness of treatment
Answer: c) Identify the client’s needs
Rationale:
Identifying the client's needs is the first step in providing appropriate care. This includes
assessing the client's condition, determining any immediate concerns, and developing a plan of
care to address those needs.
22. A nurse is planning to administer several medications to a client through a nasogastric (NG)
tube. Which of the following actions should the nurse take?
a) Mix the medications together and administer through the NG tube.
b) Crush the sublingual medication into powder form.
c) Dissolve crushed tablet medications in sterile water.
d) Flush the tube with 5 ml saline between each medication.
Answer: c) Dissolve crushed tablet medications in sterile water.
Rationale:
Crushed tablet medications should be dissolved in sterile water to prevent clogging the NG tube.
Mixing medications together could result in interactions or inconsistent dosages.
23. A nurse is preparing to perform a sterile dressing change for a client who has a surgical
wound. Which of the following actions should the nurse take to prevent contamination during the
dressing change?

a) Remove a piece of the new dressing that falls 5 cm (2 in) from the edge of the sterile field
during the dressing change.
b) Begin the dressing change by applying sterile gloves and removing the existing dressing.
c) Restart the procedure if the sterile solution splashes onto the sterile field when pouring the
solution into the dressing tray.
d) Place the existing dressing on the outermost portion of the sterile field and discard it when the
dressing change is finished.
Answer: c) Restart the procedure if the sterile solution splashes onto the sterile field when
pouring the solution into the dressing tray.
Rationale:
Any contamination of the sterile field requires restarting the procedure to maintain aseptic
technique and prevent infection.
24. A nurse is reviewing the health history of an older adult client who has a hip fracture. The
nurse should identify that which of the following findings places the client at risk for developing
a pressure injury?
a) Osteoporosis
b) Urinary incontinence
c) Macular degeneration
d) Psoriasis
Answer: b) Urinary incontinence
Rationale:
Urinary incontinence can increase the risk of pressure injuries due to moisture and irritation to
the skin.
25. A nurse is performing a focused assessment for a client who has dysrhythmia. Which of the
following indicates ineffective cardiac contractions?
a) Carotid bruit
b) Heart murmur
c) Pulse deficit
d) Bounding radial pulse

Answer: c) Pulse deficit
Rationale:
A pulse deficit occurs when there is a difference between the apical and radial pulse rates,
indicating ineffective cardiac contractions.
26. A nurse is preparing to transfer a client from a chair to the client’s bed. The client can bear
partial weight and has upper body strength. Which of the following devices should the nurse use
to transfer the client?
a) A stand-assist lift
b) A footboard
c) A slide board
d) A mechanical lift with a full-body sling
Answer: a) A stand-assist lift
Rationale:
A stand-assist lift is suitable for clients who can bear partial weight and have upper body
strength. It helps them move from a seated to a standing position with assistance.
27. A charge nurse is making assignments for the upcoming shift. Which of the following client
assignments should the charge nurse assign to a licensed practical nurse (LPN)?
a) A client who is to receive moderate (conscious) sedation.
b) A client who was just admitted with multiple rib fractures
c) A client who is scheduled for a bone marrow transplant
d) A client who has dehydration and inflammatory bowel disease.
Answer: d) A client who has dehydration and inflammatory bowel disease.
Rationale:
Dehydration and inflammatory bowel disease are conditions that an LPN can manage under the
supervision of a registered nurse. Moderate sedation, admission with multiple rib fractures, and a
bone marrow transplant require higher levels of nursing expertise.

28. A nurse is caring for a client who has a prescription for a narcotic medication. After the
medication is administered, the nurse is left with an unused portion. Which of the following
actions should the nurse take?
a) Discard the medication with another nurse as a witness
b) Send the remaining medication back to the pharmacy
c) Place the unused portion of the medication in the sharps container
d) Dispose of the unused portion of the medication in the trash
Answer: a) Discard the medication with another nurse as a witness
Rationale:
Narcotic medications should be properly disposed of in accordance with facility policy and
procedures. The nurse should discard the unused portion with another nurse as a witness to
ensure proper documentation and disposal.
29. A nurse is caring for an older adult client who has a nonpalpable skin lesion that is less than
0.5 cm (0.2 in) in diameter. Which of the following terms should the nurse use to document this
finding?
a) Papule
b) Vesicle
c) Nodule
d) Macule
Answer: d) Macule
Rationale:
A macule is a flat, nonpalpable skin lesion that is less than 0.5 cm in diameter. It is typically a
change in skin color, such as a freckle or a petechia.

Capstone Med Surg
1. A nurse is teaching a client about using a continuous positive airway pressure (CPAP) device
to treat obstructive sleep apnea. Which of the following information should the nurse include in
the teaching?
a) It delivers a preset amount of inspiratory pressure at the beginning of each breath

b) It has a continuous adjustment feature that changes the airway pressure throughout the cycle
c) It delivers a preset amount of airway pressure throughout the breathing cycle
d) It delivers positive pressure at the end of each breath
Answer: c) It delivers a preset amount of airway pressure throughout the breathing cycle
Rationale:
CPAP delivers a constant, preset amount of airway pressure throughout the breathing cycle to
keep the airway open during sleep.
2. A nurse is providing discharge teaching to a client following a heart transplant. Which of the
following information should the nurse include in the teaching?
a) Immunosuppressant medications need to be taken for up to 1 year
b) Shortness of breath might be an indication of transplant rejection
c) The surgical site will heal in 3 to 4 weeks after surgery
Answer: b) Shortness of breath might be an indication of transplant rejection
Rationale:
Shortness of breath can be a sign of transplant rejection and should be reported to the healthcare
provider immediately.
3. A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone
(SIADH) and is receiving 3% sodium chloride via continuous IV. Which of the following
laboratory findings should the nurse identify as an indication that the SIADH is resolving?
a) Urine specific gravity 1.020
b) Sodium 119 mEq/L
Answer: a) Urine specific gravity 1.020
Rationale:
A urine specific gravity within the normal range (1.005-1.030) indicates that the kidneys are
appropriately excreting water and that the SIADH is resolving.
4. A nurse is teaching a client about fecal occult blood testing (FOBT) for the screening of
colorectal cancer. Which of the following statements should the nurse include in the teaching?
a) Your provider will use stool from your digital rectal examination to perform the test

b) Your provider will prescribe a stimulant laxative prior to the procedure
c) You should begin annual fecal occult blood testing for colorectal cancer screening at 40 years
old
Answer: c) You should begin annual fecal occult blood testing for colorectal cancer screening at
40 years old
Rationale:
The American Cancer Society recommends that individuals at average risk for colorectal cancer
begin screening at age 45. Screening can be done using various methods, including FOBT,
colonoscopy, sigmoidoscopy, and others. The frequency and method of screening may vary
based on individual risk factors and preferences, so it's important for individuals to discuss
screening options with their healthcare provider.
5. A nurse is preparing a client for a colonoscopy. Which of the following medications should the
nurse anticipate the provider to prescribe as an anesthetic for the procedure?
a) Propofol
b) Pancuronium
Answer: a) Propofol
Rationale:
Propofol is commonly used as an anesthetic for colonoscopy procedures due to its fast onset and
short duration of action.
6. A nurse is reviewing the medical record of a client who has unstable angina. Which of the
findings should the nurse report to the provider?
a) Breath Sounds
b) Temperature
Answer: a) Breath Sounds
Rationale:
Unstable angina is a serious condition that can lead to a heart attack. Changes in breath sounds
could indicate the development of heart failure, which is a potential complication of unstable
angina. Therefore, the nurse should report any abnormal breath sounds to the provider for further
evaluation.

7. A nurse is caring for a client eho has burn injuries covering their upper body and is concerned
about their altered appearance. Which of the following statements should the nurse make?
a) "Your appearance will improve over time as you heal."
b) "It's understandable to feel concerned about your appearance after such injuries."
c) "Don't worry, your burns will fade with time and proper care."
d) "You should focus on your recovery rather than your appearance."
Answer: b) "It's understandable to feel concerned about your appearance after such injuries."
Rationale:
Acknowledging the client's concerns validates their feelings and shows empathy, which is
important in building a therapeutic relationship. It also opens the door for further discussion and
support.
8. A nurse is developing a plan of care for a client who will be placed in halo traction following
surgical repair of the cervical spine. Which of the following interventions should the nurse
include in the plan?
a) Inspect the pin site every 48 hr
b) Monitor the client skin under the halo vest.
c) Ensure two personnel hold the halo device when repositioning the client.
Answer: b) Monitor the client skin under the halo vest.
Rationale:
Monitoring the client's skin under the halo vest is essential to prevent pressure ulcers, which can
develop due to the device's weight and pressure on the skin. Regular monitoring can help
identify early signs of skin breakdown and prevent complications.
9. A nurse is caring for a client who has a traumatic brain injury. Which of the following findings
should indicate to the nurse the need for immediate intervention?
a) Axillary temperature 37.2°C (99°F)
b) Apical pulse 100/min
c) Respiratory rate 30/min
Answer: c) Respiratory rate 30/min

Rationale:
An elevated respiratory rate (tachypnea) can indicate increased intracranial pressure (ICP),
which is a serious complication of traumatic brain injury. Increased ICP can lead to further brain
damage and requires immediate intervention to prevent worsening of the client's condition.
10. A nurse is assessing a client who has meningitis. The nurse should identify which of the
following findings as a positive Kernig's sign?
a) After stroking the lateral area of the foot, the client's toes contract and draw together.
b) After hip flexion, the client is unable to extend their leg completely without pain.
Answer: b) After hip flexion, the client is unable to extend their leg completely without pain.
Rationale:
Kernig's sign is a physical exam finding in patients with meningitis. It is present when the leg is
flexed at the hip and knee at 90-degree angles, and subsequent extension of the knee is painful
and limited due to meningeal irritation.
11. A nurse is providing discharge teaching to a client who has heart failure and a prescription for
furosemide 20 mg PO two times daily. Which of the following instructions should the nurse
include in the teaching?
a) Monitor for increased blood pressure.
b) Increase intake of high-potassium foods.
c) Expect an increase in swelling in the hands and feet.
Answer: b) Increase intake of high-potassium foods.
Rationale:
Furosemide is a loop diuretic that can cause potassium depletion. Increasing intake of highpotassium foods can help prevent hypokalemia, a potential side effect of furosemide therapy.
12. A nurse is providing discharge instructions to a client who has GERD. Which of the
following statements by the client demonstrates an understanding of the teaching?
a) "I will eat three large meals a day to prevent hunger."
b) "I will avoid eating spicy foods."
c) "I will drink a glass of orange juice before bed."

d) "I will take a nap after eating to help with digestion."
Answer: b) "I will avoid eating spicy foods."
Rationale:
Spicy foods can irritate the stomach lining and exacerbate symptoms of GERD. Avoiding spicy
foods is a key part of managing GERD symptoms. The other options are not appropriate for
managing GERD. Eating three large meals a day can put pressure on the stomach and increase
acid reflux. Drinking orange juice before bed can increase stomach acidity, and taking a nap after
eating can worsen acid reflux.
13. A nurse at a provider's office is interviewing a client who has multiple sclerosis and has been
taking dantrolene for several months. Which of the following client statements should the nurse
identify as an indication that the medication is effective?
a) I don't have muscle spasms as frequently.
b) I haven't gotten any colds, even though it is flu season.
Answer: a) I don't have muscle spasms as frequently.
Rationale:
Dantrolene is a muscle relaxant used to treat muscle spasticity, a common symptom of multiple
sclerosis. A decrease in the frequency of muscle spasms indicates that the medication is effective
in managing the client's symptoms.
14. A nurse is assessing a client who reports a possible exposure to HIV. Which of the following
findings should the nurse identify as an early manifestation of HIV infection?
a) Stomatitis.
b) Fatigue.
c) Wasting Syndrome.
Answer: b) Fatigue.
Rationale:
Fatigue is a common early symptom of HIV infection. It can occur as the body's immune system
responds to the virus.

15. A nurse is teaching a client who has type 1 diabetes mellitus about hypoglycemia. Which of
the following statements by the client indicates an understanding of the teaching?
a) Exercise reduces the risk for hypoglycemia.
b) I can skip my insulin when I don't eat.
c) I can drink 4 ounces of soda if my blood sugar is low.
Answer: c) I can drink 4 ounces of soda if my blood sugar is low.
Rationale:
Consuming a fast-acting carbohydrate, such as soda, can help raise blood sugar quickly in cases
of hypoglycemia.
16. A nurse is teaching a client who has hypertension about dietary modifications to help control
blood pressure. Which of the following food choices should the nurse recommend the client to
include in their diet?
a) 1 packet of reconstituted dry onion soup.
b) 3 oz of lean cured ham.
c) 3 oz of chicken breast.
Answer: c) 3 oz of chicken breast.
Rationale:
Chicken breast is a lean protein source that is low in saturated fat, making it a suitable choice for
individuals with hypertension who are advised to follow a low-sodium, heart-healthy diet.
17. A nurse is planning care for a client who has acute pancreatitis. Which of the following
interventions should the nurse include in the client's plan?
a) Initiate insulin drip.
b) Monitor blood glucose levels.
c) Continue regular diet as tolerated.
d) Maintain NPO status until pain-free.
e) Manage acute pain.
Answer: b) Monitor blood glucose levels.
d) Maintain NPO status until pain-free.
e) Manage acute pain.

Rationale:
Monitoring blood glucose levels is important in clients with acute pancreatitis due to the risk of
hyperglycemia. Maintaining NPO status until pain-free helps rest the pancreas and reduce
pancreatic stimulation. Managing acute pain is essential for the client's comfort and may include
pain medications and positioning for comfort.

Capstone Mental health
1. A nurse is creating a plan of care for a client who has panic disorder. Which of the following
interventions should the nurse include?
a) Encourage the client to participate in group therapy sessions
b) Use simple words to describe procedures to the client
c) Provide the client with a list of relaxation techniques
d) Suggest the client avoid situations that may trigger panic attacks
Answer: b) Use simple words to describe procedures to the client
Rationale:
Individuals with panic disorder can become overwhelmed easily, so using simple and clear
language when explaining procedures can help reduce anxiety and improve understanding.
2. A nurse is caring for a client experiencing visual hallucinations followed by impaired
consciousness as a result of alcohol withdrawal. Which of the following conditions should the
nurse identify as causing these manifestations?
a) Delirium
b) Schizophrenia
c) Bipolar disorder
d) Substance-induced psychotic disorder
Answer: a) Delirium
Rationale:
Delirium, characterized by disturbances in consciousness and cognition, can occur during
alcohol withdrawal and may present with visual hallucinations and impaired consciousness.

3. A nurse is teaching a male client who has a depressive disorder about sertraline. Which of the
following information should the nurse include in the teaching?
a) "This medication is habit-forming, so take it only as needed."
b) "You should expect to see improvement in your symptoms within a few days."
c) "This medication may cause an inability to orgasm."
d) "It is safe to consume alcohol while taking this medication."
Answer: c) "This medication may cause an inability to orgasm."
Rationale:
Sertraline, like other SSRIs, can cause sexual side effects, including an inability to orgasm,
which should be discussed with the client to manage expectations and provide informed consent.
4. A nurse is conducting a child maltreatment screening of a family who has a toddler. Which of
the following findings is an indicator of possible child neglect?
a) The child has a history of accidental falls
b) The child has a full set of baby teeth
c) The child has had no immunizations since birth
d) The child has an imaginary friend
Answer: c) The child has had no immunizations since birth
Rationale:
Failure to provide necessary medical care, such as immunizations, can be an indicator of child
neglect, which is a form of child maltreatment.
5. A nurse is preparing to teach a client who has major depressive disorder and is scheduled to
undergo electroconvulsive therapy (ECT). Which of the following statements should the nurse
include in the teaching?
a) "ECT is a long-term treatment for depression."
b) "ECT is only used when other treatments have failed."
c) "ECT is delivered through electrodes attached to the head."
d) "ECT is a painless procedure."
Answer: c) "ECT is delivered through electrodes attached to the head."
Rationale:

Providing accurate information about the procedure, including how it is delivered, can help
alleviate anxiety and prepare the client for what to expect during electroconvulsive therapy
(ECT).
6. A charge nurse is planning an in-service for newly licensed nurses on tort law in mental health
care. Which of the following scenarios should the charge nurse provide as an example of an
unintentional tort?
a) A nurse intentionally restricts a client's access to visitors without proper justification.
b) A nurse fails to obtain informed consent from a client before administering a medication.
c) A nurse did not clarify a client prescription that was difficult to read, resulting in a medication
error.
d) A nurse shares a client's confidential information with unauthorized individuals.
Answer: c) A nurse did not clarify a client prescription that was difficult to read, resulting in a
medication error.
Rationale:
An unintentional tort, such as negligence, occurs when harm is caused by failure to exercise
reasonable care, as in the case of a medication error due to unclear instructions.
7. A nurse is reviewing the medical records of a group of clients. For which of the following
clients should the nurse recommend a referral for assertive community treatment (ACT)?
a) A client who has a stable support system and follows up with outpatient appointments.
b) A client who has a history of anxiety and receives counseling once a week.
c) A client who has repeated acute care admissions due to schizophrenia.
d) A client who has bipolar disorder and is compliant with medication management.
Answer: c) A client who has repeated acute care admissions due to schizophrenia.
Rationale:
Assertive community treatment (ACT) is a model of care for individuals with severe mental
illness who have difficulty engaging in traditional outpatient services, such as those with
repeated acute care admissions.

8. A nurse is assessing a client who has delirium as a result of sepsis. Which of the following is
apply.
a) Rapid mood changes
b) Hallucinations
c) Restlessness
d) Euphoria
Answer: a) Rapid mood changes
b) Hallucinations
c) Restlessness
Rationale:
Delirium, especially in the context of sepsis, can present with a variety of symptoms, including
rapid mood changes, hallucinations, and restlessness.
9. A nurse is admitting a client to an alcohol abuse program. The client states, "I'm here because
of my boss. It was part of my job to go to parties and drink with clients." The client's statement is
an example of which of the following defense mechanisms?
a) Displacement
b) Projection
c) Rationalization
d) Sublimation
Answer: c) Rationalization
Rationale:
Rationalization is a defense mechanism in which an individual justifies their behavior by
providing logical, but often false, reasons or excuses.
10. A charge nurse in a community mental health clinic is discussing ethical concepts of client
care with a newly licensed nurse. The charge nurse should use which of the following situations
as an Example of fidelity?
a) Attending an educational conference on identifying clients at risk of suicide.
b) Providing a client with information about community resources.
c) Advocating for a client's rights during a treatment team meeting.

d) Ensuring a client's confidentiality during a counseling session.
Answer: a) Attending an educational conference on identifying clients at risk of suicide.
Rationale:
Fidelity refers to the ethical principle of honoring commitments and being faithful to agreements,
such as attending educational conferences to improve knowledge and skills for better client care.
11. A nurse on an inpatient mental health unit is caring for a client who has major depressive
disorder and malnutrition. Which of the following actions should the nurse take to improve the
client's nutritional status?
a) Offer the client a variety of food options at each meal.
b) Encourage the client to eat three large meals a day.
c) Weigh the client at the same time every morning.
d) Provide the client with high-calorie snacks between meals.
Answer: c) Weigh the client at the same time every morning.
Rationale:
Weighing the client at the same time every morning helps monitor changes in weight, which can
indicate improvements or declines in nutritional status.
12. A nurse is caring for a client who is receiving haloperidol 2 mg IM every 6 hr. Available is
haloperidol 5 mg/ml. How many ml should the nurse administer? (Round the answer to the
nearest tenth. Use a leading zero if it applies.)
Answer: 0.4 ml
Rationale:
To calculate the amount to administer, divide the prescribed dose by the concentration of the
medication: 2 mg / 5 mg/ml = 0.4 ml.
13. A nurse on an inpatient eating disorders unit is caring for a client who has anorexia nervosa
and has a body mass index of 17.2. Which of the following actions should the nurse take? (Select
all that apply).
a) Provide the client with small meals frequently
b) Monitor the client's weight daily

c) Allow the client to choose the meals she will eat
d) Stay with the client during meals and for 1 hr afterward
e) Offer specific privileges for sustained weight gain
Answer: a) Provide the client with small meals frequently
b) Monitor the client's weight daily
d) Stay with the client during meals and for 1 hr afterward
e) Offer specific privileges for sustained weight gain
Rationale:
These actions are appropriate for managing anorexia nervosa and promoting weight gain and
recovery.
14. A nurse is caring for a client who has bipolar disorder. The client says to the nurse, "Give me
your pen." The nurse should identify that the client is at risk for which of the following?
a) Self-mutilation
b) Homicidal ideation
c) Suicidal ideation
d) Impulse control disorder
Answer: a) Self-mutilation
Rationale:
Clients with bipolar disorder, especially during manic episodes, may engage in impulsive or
risky behaviors, such as self-mutilation.
15. A nurse is caring for a client who has dementia and insists a doll is her infant child. Which
approach should the nurse use when interacting with the client?
a) Reality orientation
b) Distraction techniques
c) Validation therapy
d) Reminiscence therapy
Answer: c) Validation therapy
Rationale:

Validation therapy involves acknowledging and respecting the feelings and beliefs of individuals
with dementia, even if they differ from reality, which can help reduce distress and improve
communication.
16. A nurse is discharging a client who was admitted for the treatment of alcohol withdrawal.
Which of the following resources should be recommended to the client?
a) Reach to Recovery
b) A 12-step program
c) Al-Anon
d) Light therapy
Answer: b) A 12-step program
Rationale:
A 12-step program, such as Alcoholics Anonymous (AA), can provide ongoing support and
resources for individuals recovering from alcohol addiction.
17. A nurse is conducting an admission assessment for a client experiencing a manic episode of
bipolar disorder. Which of the following behaviors should the nurse expect? Select all that apply.
a) Grandiosity
b) Flight of ideas
c) Hyperactivity
d) Flat affect
Answer: a) Grandiosity
b) Flight of ideas
c) Hyperactivity
Rationale:
These behaviors are characteristic of a manic episode in bipolar disorder, including grandiosity
(e.g., inflated self-esteem or belief in special powers), flight of ideas (rapid, often disjointed
thoughts), and hyperactivity (excessive physical activity).
1. A nurse is assessing a client who started taking furosemide 2 days ago and has a potassium
level of 3.1. Which of the following findings should the nurse expect?

a) Increased blood pressure
b) Depressed deep tendon reflexes
c) Increased heart rate
d) Increased urinary output
Answer: b) Depressed deep tendon reflexes
Rationale:
Furosemide is a loop diuretic that can cause hypokalemia (low potassium levels), which can lead
to depressed deep tendon reflexes among other symptoms.
2. A nurse is caring for a client who has an infection and is starting to take gentamicin. Which of
the following client laboratory tests should the nurse monitor to detect an adverse effect of the
medication?
a) Liver function tests
b) White blood cell count
c) Platelet count
d) Creatinine
Answer: d) Creatinine
Rationale:
Gentamicin can cause nephrotoxicity (kidney damage), so monitoring creatinine levels is
important to detect any adverse effects on kidney function.
3. A nurse is administering bumetanide to a client who has ascites. The nurse should recognize
that which of the following findings is an expected therapeutic effect of this medication?
a) Decreased urinary output
b) Decreased serum sodium levels
c) Increased urinary output
d) Increased serum potassium levels
Answer: c) Increased urinary output
Rationale:
Bumetanide is a loop diuretic that increases urinary output, which helps reduce fluid retention in
conditions like ascites.

4. A nurse is providing teaching to a client who has fibromyalgia and a new prescription for
pregabalin. Which of the following instructions should the nurse include in the teaching?
a) You should take this medication on an empty stomach.
b) You should avoid activities that require mental alertness, such as driving.
c) You should notify your provider if you experience facial swelling.
d) You should expect to see improvement in your symptoms within a few days.
Answer: c) You should notify your provider if you experience facial swelling.
Rationale:
Pregabalin can rarely cause serious allergic reactions, including facial swelling, which should be
reported to the provider immediately.
5. A nurse is assessing a client who is in preterm labor and is receiving magnesium via
continuous IV infusion. Which of the following findings should the nurse identify as the
priority?
a) Blood pressure 140/90 mmHg
b) Respiratory rate 16/min
c) Deep tendon reflexes 1+
d) Urinary output 50 mL/hr
Answer: c) Deep tendon reflexes 1+
Rationale:
Magnesium toxicity can occur with excessive magnesium levels, leading to depressed deep
tendon reflexes, which is a serious concern that requires immediate intervention to prevent
further complications.
6. A nurse is caring for a client who has a systemic fungal infection and is receiving IV
amphotericin B deoxycholate. During a previous infusion, the client experienced chills and fever.
Which of the following actions should the nurse take to minimize these effects during the next
infusion?
a) Administer diphenhydramine prior to administration.
b) Increase the infusion rate gradually over 30 minutes.

c) Administer acetaminophen prior to administration.
d) Infuse a 0.9% sodium chloride solution prior to administration.
Answer: a) Administer diphenhydramine prior to administration.
Rationale:
Diphenhydramine is an antihistamine that can help reduce the chills and fever associated with
amphotericin B infusions. It is often given prophylactically to minimize these side effects.
7. A nurse is providing teaching to a client who has rheumatoid arthritis and is starting to take
hydroxychloroquine. Which of the following client statements indicates an understanding of the
teaching?
a) "I will need to have regular eye exams while taking this medication."
b) "I can stop taking this medication once my symptoms improve."
c) "I should take this medication on an empty stomach."
d) "I should avoid using sunscreen while taking this medication."
Answer: a) "I will need to have regular eye exams while taking this medication."
Rationale:
Hydroxychloroquine can cause retinal toxicity, so regular eye exams are necessary to monitor for
this side effect.
8. A nurse is monitoring a client who is receiving a continuous IV infusion of dopamine. Which
of the following findings requires immediate intervention by the nurse?
a) Heart rate of 90/min
b) Blood pressure of 110/70 mm Hg
c) Urine output of 30 mL/hr
d) Infiltration of peripheral IV
Answer: d) Infiltration of peripheral IV
Rationale:
Infiltration of the peripheral IV can lead to tissue damage and is a priority for immediate
intervention to prevent complications.

9. A nurse is providing discharge instructions to a client who has a new prescription for
omeprazole for the treatment of GERD. Which of the following statements by the client indicates
an understanding of the teaching?
a) "This medication reduces stomach acid."
b) "I should take this medication with meals."
c) "I can take this medication as needed for heartburn."
d) "I should take this medication at bedtime only."
Answer: a) "This medication reduces stomach acid."
Rationale:
Omeprazole is a proton pump inhibitor that reduces the production of stomach acid, which helps
in the treatment of GERD.
10. A nurse is providing teaching to a client who has prostate cancer and a new prescription for
leuprolide. The nurse should explain to the client that leuprolide treats prostate cancer by which
of the following actions?
a) Leuprolide decreases the production of testosterone.
b) Leuprolide increases the production of testosterone.
c) Leuprolide blocks the action of estrogen.
d) Leuprolide promotes the growth of prostate cells.
Answer: a) Leuprolide decreases the production of testosterone.
Rationale:
Leuprolide is a gonadotropin-releasing hormone (GnRH) agonist that suppresses the production
of testosterone, which is often used in the treatment of prostate cancer to slow the growth of the
cancer cells.
11. A nurse is reviewing laboratory data for a client who is taking niacin to correct plasma lipid
levels. Which of the following findings should the nurse identify as an adverse effect of this
therapy?
a) Elevated Alanine Aminotransferase (ALT)
b) Decreased White Blood Cell (WBC) count
c) Increased Platelet count

d) Elevated Blood Urea Nitrogen (BUN)
Answer: a) Elevated Alanine Aminotransferase (ALT)
Rationale:
Niacin, also known as vitamin B3, can cause liver toxicity, which can manifest as elevated liver
enzymes such as ALT.
12. A nurse is caring for a client who requires a transfusion of one unit of packed RBCs. The
nurse received the following prescription: diphenhydramine 50mg by mouth once, one hour prior
to transfusion. The nurse should identify this as which of the following types of prescription?
a) Standing prescription
b) Single prescription
c) Stat prescription
d) PRN prescription
Answer: b) Single prescription
Rationale:
A single prescription is for a medication to be given once at a specific time or before a specific
procedure, such as before a transfusion in this case.
13. A nurse is caring for a client who has hyperlipidemia and a new prescription for colesevelam.
The nurse should monitor the client for which of the following manifestations as an adverse
effect of colesevelam?
a) Diarrhea
b) Constipation
c) Nausea
d) Headache
Answer: b) Constipation
Rationale:
Colesevelam is a bile acid sequestrant used to lower cholesterol. One common side effect is
constipation due to its mechanism of action in the digestive tract.

14. A nurse is caring for an older adult client who is confirmed positive for HIV and will begin
medication therapy. Which of the following instructions should the nurse give the client? (Select
all that apply.)
a) "You will be prescribed more than one medication to fight the virus."
b) "Your medication plan can also include an antibiotic medication."
c) "You will need to take medication for the rest of your life."
Answer: a) "You will be prescribed more than one medication to fight the virus."
b) "Your medication plan can also include an antibiotic medication."
c) "You will need to take medication for the rest of your life."
Rationale:
HIV treatment typically involves a combination of medications, including antiretroviral drugs to
fight the virus and sometimes antibiotics to prevent or treat infections. HIV is a chronic
condition, so medication is usually lifelong.
15. A nurse is completing an admission assessment for a client who has been taking St. John's
wort. The nurse should identify that which of the following medications can interact with St.
John's wort?
a) Citalopram
b) Furosemide
c) Insulin
d) Warfarin
Answer: a) Citalopram
Rationale:
St. John's wort can interact with many medications, including citalopram, a selective serotonin
reuptake inhibitor (SSRI), potentially leading to serotonin syndrome or reducing the
effectiveness of the antidepressant.
16. The first action the nurse should take is to assess the client for injury due to a medication
error.
a) Assess the client
b) Notify the healthcare provider

c) Document the error
d) Implement measures to prevent further errors
Answer: a) Assess the client
Rationale:
Assessing the client for any potential injury or adverse effects of the medication error is the
priority to ensure the client's safety and well-being.
17. A nurse is providing teaching to a client who has angina and a new prescription for
sublingual nitroglycerine tablets. Which of the following instructions should the nurse include in
the teaching?
a) Store used tablets at room temperature.
b) Chew the tablets for quicker absorption.
c) Take the tablets with a full glass of water.
d) Keep the tablets in the refrigerator.
Answer: a) Store used tablets at room temperature.
Rationale:
Nitroglycerine tablets should be stored in their original container at room temperature, protected
from light and moisture. They should not be stored in the refrigerator.
18. A nurse is teaching a client who has a new prescription for benzonatate. Which of the
following statements by the client indicates understanding of the teaching?
a) "I should not drive while taking this medication."
b) "I can take this medication with meals."
c) "I should take this medication as needed for cough."
d) "I should take this medication with a full glass of water."
Answer: a) "I should not drive while taking this medication."
Rationale:
Benzonatate is a cough suppressant that can cause drowsiness and dizziness, so it is important
for the client to avoid driving or operating heavy machinery while taking this medication.

19. A nurse is assessing a client who has diabetes insipidus and is starting intranasal
desmopressin. Which of the following findings should indicate to the nurse that the medication is
effective?
a) The client's 24-hour urine output is 1256 mL.
b) The client's blood glucose level is 200 mg/dL.
c) The client's blood pressure is 150/90 mm Hg.
d) The client's serum potassium level is 3.2 mEq/L.
Answer: a) The client's 24-hour urine output is 1256 mL.
Rationale:
Desmopressin is a synthetic form of vasopressin used to treat diabetes insipidus by decreasing
urine output. A decrease in urine output would indicate that the medication is effective in
reducing excessive urine production.
20. A nurse is transcribing a telephone prescription for acetaminophen 650 mg by mouth daily at
bedtime. The nurse should identify that which of the following abbreviations are acceptable to
use when transcribing the prescription?
a) Abbreviate by mouth as PO
b) Abbreviate daily as QD
c) Abbreviate at bedtime as HS
d) Abbreviate acetaminophen as APAP
Answer: a) Abbreviate by mouth as PO
Rationale:
"PO" is the accepted abbreviation for "by mouth" in medication orders. "QD" is the abbreviation
for "daily," "HS" is the abbreviation for "at bedtime," and "APAP" is an abbreviation for
acetaminophen but is not commonly used in medication orders.
21. A nurse is reviewing the medical record of a client who takes lithium. Which of the following
findings is the priority to report to the provider?
a) Sodium 130
b) Potassium 4.0
c) Calcium 9.0

d) Magnesium 2.0
Answer: a) Sodium 130
Rationale:
Lithium can cause hyponatremia (low sodium levels), which can be a serious side effect
requiring immediate intervention. It is important to report this finding to the provider promptly.
22. What is an adverse effect of iron preparation?
a) Monitor your child for constipation (increase fluid)
b) Decrease the intake of dairy products
c) Administer with meals
d) Take with an antacid
Answer: a) Monitor your child for constipation (increase fluid)
Rationale:
Iron preparations commonly cause constipation, especially in children. Increasing fluid intake
can help alleviate this side effect.
23. A nurse is teaching a client who has a seizure disorder and has a new prescription for
phenytoin. Which of the following client statements indicates an understanding of the teaching?
a) "I will have my blood checked to monitor the medication levels."
b) "I will stop taking my medication if I feel better."
c) "I can drink alcohol in moderation while taking this medication."
d) "I should take this medication on an empty stomach."
Answer: a) "I will have my blood checked to monitor the medication levels."
Rationale:
Phenytoin is a medication that requires monitoring of blood levels to ensure it remains within the
therapeutic range. This statement indicates the client understands the importance of this
monitoring.
25. A nurse is reviewing the medical record of a client who has asthma and takes albuterol.
Which of the following findings should the nurse identify as an adverse effect of albuterol?
a) Heart rate 110 bpm

b) Respiratory rate 18 breaths/min
c) Blood pressure 120/80 mm Hg
d) Oxygen saturation 98%
Answer: a) Heart rate 110 bpm
Rationale:
Albuterol is a bronchodilator that can cause tachycardia (increased heart rate) as an adverse
effect. This should be monitored, especially in clients with cardiovascular conditions.
26. A nurse is assessing a client who has a prescription for haloperidol 0.5 mg PO three times
daily. The medication administration record shows that the client received 5 mg per dose on the
previous day. Which of the following manifestations is the nurse’s priority to assess?
a) Drowsiness
b) Dry mouth
c) Muscle stiffness
d) Blurred vision
Answer: c) Muscle stiffness
Rationale:
Haloperidol is an antipsychotic medication that can cause extrapyramidal symptoms (EPS) such
as muscle stiffness, which can be a sign of a serious condition called neuroleptic malignant
syndrome (NMS). Monitoring for and assessing EPS is crucial, especially in cases of overdose.
27. A nurse is teaching a client who has a new prescription for isoniazid to treat tuberculosis.
Which of the following information should the nurse include in the teaching?
a) "You will have frequent sputum tests to monitor the effectiveness of this medication."
b) "You should take this medication with a full glass of milk."
c) "You can stop taking the medication once you start feeling better."
d) "You may experience yellowing of the skin as a common side effect."
Answer: a) "You will have frequent sputum tests to monitor the effectiveness of this
medication."
Rationale:

Monitoring sputum tests is important to assess the effectiveness of isoniazid in treating
tuberculosis and to detect any drug resistance that may develop.
28. A nurse is assessing a client who received ondansetron 1 hour ago. Which of the following
findings should the nurse identify as a therapeutic effect?
a) Suppressed emesis
b) Increased appetite
c) Dry mouth
d) Constipation
Answer: a) Suppressed emesis
Rationale:
Ondansetron is an antiemetic medication used to treat nausea and vomiting. A therapeutic effect
of ondansetron is the suppression of emesis (vomiting).
29. A nurse is caring for a client who is at risk for alcohol withdrawal delirium. Which of the
following medications should the nurse expect the provider to prescribe?
a) Chlordiazepoxide
b) Olanzapine
c) Lorazepam
d) Haloperidol
Answer: a) Chlordiazepoxide
Rationale:
Chlordiazepoxide is a benzodiazepine medication commonly used to prevent and treat alcohol
withdrawal symptoms, including delirium.
30. A nurse is providing teaching to a client who has erectile dysfunction and has a new
prescription for tadalafil. Which of the following client statements indicates an understanding of
the teaching?
a) "This medication can decrease blood pressure."
b) "I should take this medication with grapefruit juice."
c) "I can take this medication as needed for sexual activity."

d) "I should take this medication with a high-fat meal."
Answer: a) "This medication can decrease blood pressure."
Rationale:
Tadalafil, a phosphodiesterase type 5 (PDE5) inhibitor, can lower blood pressure. It is important
for the client to be aware of this potential side effect, especially if they are taking medications for
hypertension.
31. A nurse is assessing a group of clients. Which of the following findings is the priority to
report to the provider?
a) A client who is receiving continuous IV lidocaine and has a respiratory rate of 10/min
b) A client who is receiving IV heparin and has a platelet count of 120,000/mm³
c) A client who is receiving IV vancomycin and has redness at the IV site
d) A client who is receiving IV furosemide and has a potassium level of 3.5 mEq/L
Answer: a) A client who is receiving continuous IV lidocaine and has a respiratory rate of
10/min
Rationale:
A respiratory rate of 10/min is below the normal range and could indicate respiratory depression,
a potential side effect of lidocaine toxicity. This finding should be reported immediately to the
provider for further evaluation and intervention.

Maternal Newborn Assessment
1. A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation and has
a urinary tract infection. Which of the following findings should the nurse report to the provider?
a) WBC count 11,000/mm³
b) Hgb 11.2 g/dL
c) Hct 34%
d) Platelets 140,000/mm³
Answer: d) Platelets 140,000/mm³
Rationale:

The platelet count of 140,000/mm³ is lower than the normal range during pregnancy (150,000 to
400,000/mm³) and may indicate thrombocytopenia, which requires further evaluation and
management, especially in the context of a urinary tract infection.
2. A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe
features. Which of the following actions should the nurse take?
a) Restrict protein intake to less than 40 g/day.
b) Initiate seizure precautions for the client.
c) Initiate an infusion of 0.9% sodium chloride at 150 mL/hr.
d) Encourage the client to ambulate twice per day.
Answer: b) Initiate seizure precautions for the client.
Rationale:
Preeclampsia with severe features is a serious condition that can lead to seizures (eclampsia).
Therefore, initiating seizure precautions is a priority to ensure the safety of the client.
3. A nurse is caring for a client who is in the transition phase of labor. Which of the following
actions should the nurse take?
a) Assist the client to void every 3 hr.
b) Monitor contractions every 30 min.
c) Place the client into a lithotomy position.
d) Encourage the client to use a pant-blow breathing pattern.
Answer: a) Assist the client to void every 3 hr.
Rationale:
It is important to assist the client to void regularly during labor to prevent bladder distention,
which can impede the progress of labor. Voiding every 3 hours helps ensure that the bladder is
not too full.
4. A nurse is teaching the parents of a newborn how to care for their child’s uncircumcised penis.
Which of the following instructions should the nurse include?
a) Retract the foreskin until you feel resistance.
b) Use a cotton swab to clean under the foreskin.

c) Apply petroleum jelly to the foreskin.
d) Wash the penis once per day with soap and water.
Answer: d) Wash the penis once per day with soap and water.
Rationale:
For uncircumcised infants, the foreskin should not be retracted forcibly, as it may cause injury or
adhesions. Instead, the penis should be gently washed once a day with soap and water, and the
foreskin should be left alone to retract naturally over time.
5. A nurse is assessing a client who is at 31 weeks of gestation. Which of the following findings
indicate a potential prenatal complication?
a) Periodic tingling of fingers
b) Absence of clonus
c) Leg cramps
d) Blurred vision
Answer: d) Blurred vision
Rationale:
Blurred vision can be a sign of preeclampsia, a serious complication of pregnancy characterized
by high blood pressure and organ damage. It is important to monitor this client closely and report
any signs of preeclampsia to the healthcare provider.
6. A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the
umbilical cord protruding through the cervix. Which of the following actions should the nurse
take?
a) Administer oxytocin to the client via intravenous infusion.
b) Apply oxygen at 2 L/min via nasal cannula.
c) Prepare for insertion of an intrauterine pressure catheter.
d) Assist the client into the knee-chest position.
Answer: d) Assist the client into the knee-chest position.
Rationale:

The knee-chest position helps relieve pressure on the umbilical cord and can prevent further cord
compression, which is essential to maintain fetal oxygenation until emergency delivery can be
accomplished.
7. A nurse is providing dietary teaching for a client who is at 29 weeks of gestation and has
phenylketonuria. Which of the following suggested foods should the nurse include in the
teaching?
a) A peanut butter sandwich on wheat bread.
b) A sliced apple and red grapes.
c) A chocolate chip cookie with a glass of skim milk.
d) A scrambled egg with cheddar cheese.
Answer: d) A scrambled egg with cheddar cheese.
Rationale:
Phenylketonuria (PKU) is a genetic disorder that requires a low-phenylalanine diet. Eggs and
cheese are low in phenylalanine, making them suitable choices for individuals with PKU.
8. A nurse on a postpartum unit is receiving change-of-shift report for four clients. Which of the
following clients should the nurse plan to assess first?
a) A client who gave birth 1 day ago and needs Rh (D) immune globulin.
b) A client who gave birth 3 days ago and reports breath fullness.
c) A client who gave birth 12 hours ago and reports an increase in urinary output.
d) A client who gave birth 8 hours ago and is saturating a perineal pad every hour.
Answer: d) A client who gave birth 8 hours ago and is saturating a perineal pad every hour.
Rationale:
Saturating a perineal pad every hour indicates excessive postpartum bleeding (postpartum
hemorrhage), which requires immediate assessment and intervention to prevent complications.
9. A nurse is assessing a newborn who is 48 hours old and has a maternal history of methadone
use during pregnancy. Which of the following manifestations should the nurse identify as an
indication of neonatal abstinence syndrome?
a) Hyporeactivity

b) Excessive high-pitched cry
c) Acrocyanosis
d) Respiratory rate of 50/min
Answer: b) Excessive high-pitched cry
Rationale:
Neonatal abstinence syndrome (NAS) is a withdrawal syndrome that occurs in newborns
exposed to drugs in utero. An excessive, high-pitched cry is a common manifestation of NAS.
10. A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes
recurrent variable decelerations on the fetal monitor. Which of the following actions should the
nurse take first?
a) Prepare the equipment necessary to initiate an amnioinfusion.
b) Administer oxygen at 10 L/min via nonrebreather face mask.
c) Discontinue the infusion of oxytocin.
d) Place the client in a left lateral position.
Answer: d) Place the client in a left lateral position.
Rationale:
Variable decelerations can indicate umbilical cord compression. Placing the client in a left lateral
position can help relieve pressure on the umbilical cord and improve fetal oxygenation.
11. A nurse is admitting a client who is at 35 weeks of gestation and is experiencing mild vaginal
bleeding due to placenta previa. Which of the following actions should the nurse plan to take?
a) Initiate continuous monitoring of the FHR.
b) Administer a dose of betamethasone.
c) Check the cervix for dilation every 8 hr.
d) Request that the provider prescribe misoprostol PRN.
Answer: a) Initiate continuous monitoring of the FHR.
Rationale:
Placenta previa can lead to significant bleeding, which can compromise fetal well-being.
Continuous monitoring of the fetal heart rate (FHR) is essential to assess for signs of fetal
distress.

12. A nurse is reviewing a laboratory results for a client who is at 33 weeks of gestation and has
preeclampsia. Which of the following laboratory results should the nurse report to the provider?
a) BUN 35 mg/dL
b) Hgb 15 mg/dL
c) Bilirubin 0.6 mg/dL
d) Hct 37%
Answer: a) BUN 35 mg/dL
Rationale:
An elevated blood urea nitrogen (BUN) level can indicate impaired kidney function, which is a
concern in preeclampsia. The nurse should report this finding to the provider for further
evaluation and management.
13. A nurse is assessing a newborn who was born vaginally with vacuum extractor assistance and
notes the presence of soft, raised swellings on the newborn's head that cross the suture line. The
nurse should identify the swellings as which of the following?
a) Nevus flammeus
b) Caput succedaneum
c) Cephalohematoma
d) Erythema toxicum
Answer: c) Cephalohematoma
Rationale:
Cephalohematoma is a collection of blood between the periosteum and the skull bone that does
not cross suture lines. Caput succedaneum, on the other hand, is a soft, raised swelling on the
scalp that crosses suture lines and is caused by pressure from the vaginal wall during birth.
14. A nurse is assessing a newborn who is 48 hours old and is experiencing opioid withdrawals.
Which of the following findings should the nurse expect?
a) Hypotonicity
b) Moderate tremors of the extremities
c) Axillary temperature 36.1°C (96.9°F)

d) Excessive sleeping
Answer: b) Moderate tremors of the extremities
Rationale:
Opioid withdrawal in newborns can cause symptoms such as tremors, irritability, poor feeding,
and diarrhea. Moderate tremors of the extremities are a common manifestation of opioid
withdrawal in newborns.
15. A nurse is caring for a client who is receiving oxytocin to augment labor. The client has an
intrauterine pressure catheter and an internal fetal scalp electrode for monitoring. Which of the
following is an indication that the nurse should discontinue the infusion?
a) Contraction frequency every 3 min
b) Contraction duration of 100 seconds
c) Fetal heart rate with moderate variability
d) Fetal heart rate of 118/min
Answer: b) Contraction duration of 100 seconds
Rationale:
A contraction duration of 100 seconds is excessively long and can lead to uteroplacental
insufficiency, which can compromise fetal oxygenation. Discontinuing the oxytocin infusion is
necessary to prevent further complications.
16. A nurse is providing teaching to a group of women about risk factors for ovarian cancer.
Which of the following should the nurse include? (Select all that apply.)
a) Nulliparity
b) History of breastfeeding
c) Previous use of oral contraceptives
d) History of breast cancer
E. Hormone replacement therapy
Answer: a) Nulliparity
c) Previous use of oral contraceptives
d) History of breast cancer
E. Hormone replacement therapy

Rationale:
Risk factors for ovarian cancer include nulliparity (never having given birth), a history of
breastfeeding (protective factor), previous use of oral contraceptives (protective factor), history
of breast cancer (may indicate genetic predisposition), and hormone replacement therapy (longterm use increases risk).
17. A nurse is caring for a client who is in active labor and notes late decelerations in the FHR on
the external fetal monitor. Which of the following actions should the nurse take first?
a) Change the client’s position.
b) Palpate the uterus to assess for tachysystole.
c) Increase the client’s IV infusion rate.
d) Administer oxygen at 10 L/min via nonrebreather mask.
Answer: a) Change the client’s position.
Rationale:
Late decelerations indicate uteroplacental insufficiency. Changing the client's position, especially
to a left lateral position, can improve placental perfusion and fetal oxygenation, addressing the
cause of the late decelerations.
18. A nurse is caring for a client who is in labor and has an epidural for pain control. Which of
the following clinical manifestations should the nurse expect as an adverse effect of epidural
anesthesia?
a) Polyuria
b) Hypertension
c) Pruritus
d) Dry mouth
Answer: b) Hypertension
Rationale:
Hypertension is a potential adverse effect of epidural anesthesia due to sympathetic blockade,
which can lead to vasodilation and decreased vascular tone.

19. A nurse is caring for a client who is in labor and has a diagnosis of group B streptococcus Bhemolytic infection. Which of the following medications should the nurse plan to administer?
a) Ampicillin
b) Azithromycin
c) Ceftriaxone
d) Acyclovir
Answer: a) Ampicillin
Rationale:
Ampicillin is the first-line antibiotic for intrapartum prophylaxis against group B streptococcus
(GBS) in pregnant women to prevent neonatal GBS infection. It is typically administered
intravenously during labor.

CAPSTONE PEDIATRY
1. A nurse on a pediatric unit is receiving change-of-shift report on a group of clients. Which of
the following clients should the nurse assess first?
a) A child who had a cardiac catheterization using the femoral artery and has blanching of the
toes.
b) A child who has asthma and is reporting shortness of breath after using an inhaler.
c) A child who has a new diagnosis of diabetes mellitus and a blood glucose level of 250 mg/dL.
d) A child who is scheduled for surgery in the morning and is NPO.
Answer: a) A child who had a cardiac catheterization using the femoral artery and has blanching
of the toes.
Rationale:
Blanching of the toes can indicate compromised blood flow and potential arterial occlusion,
which is a medical emergency that requires immediate assessment and intervention.
2. A nurse is providing teaching to an adolescent who has a new prescription for cefazolin. For
which of the following should the nurse instruct the adolescent to monitor and report to the
provider?
a) Dry mouth

b) Constipation
c) Back pain
d) Urticaria
Answer: d) Urticaria
Rationale:
Urticaria (hives) can indicate an allergic reaction to the medication, which can escalate to more
severe reactions, including anaphylaxis. Immediate reporting and assessment are necessary.
3. A nurse in the emergency department is caring for a preschooler who has epiglottitis. Which of
the following actions should the nurse take?
a) Place the child in a left lateral position.
b) Obtain a specimen from the child’s throat for culture.
c) Inspect the child’s throat with a padded tongue depressor.
d) Initiate droplet precautions for the child.
Answer: d) Initiate droplet precautions for the child.
Rationale:
Initiating droplet precautions is essential to prevent the spread of the infection. Inspecting the
throat with a tongue depressor can cause a laryngospasm, which is why it should be avoided.
4. A nurse is caring for an infant who has gastroesophageal reflux (GER). Which of the
following actions should the nurse take to prevent regurgitation? Select all that apply.
a) Thicken the infant’s formula with cereal.
b) Avoid giving the infant citrus juices.
c) Position the child with their head elevated after meals.
d) Burp the infant frequently during feedings.
e. Feed the infant a large amount of formula before bedtime.
Answer: a) Thicken the infant’s formula with cereal.
b) Avoid giving the infant citrus juices.
c) Position the child with their head elevated after meals.
Rationale:

Thickening the formula helps it stay down better, avoiding citrus juices prevents irritation of the
esophagus, and keeping the head elevated after meals helps reduce reflux by utilizing gravity.
5. A nurse is providing teaching to the parent of a child about home care following a cardiac
catheterization. Which of the following statements should the nurse include?
a) You should give your child aspirin if they report pain at the site.
b) You can remove the pressure dressing 8 hours after the procedure.
c) Your child can soak in the bathtub 24 hours after the procedure.
d) Your child should avoid strenuous physical activities for several days.
Answer: d) Your child should avoid strenuous physical activities for several days.
Rationale:
Avoiding strenuous physical activities is crucial to prevent complications such as bleeding at the
catheter insertion site. The other options are incorrect as they may lead to adverse outcomes or
are not advised in post-catheterization care.
6. A nurse is assessing a toddler who is toilet trained and has recently started wetting the bed.
Which of the following findings should the nurse recognize as an indication of a urinary tract
infection (UTI)?
a) Steatorrhea
b) Jaundice
c) Incontinence
d) Rebound tenderness
Answer: c) Incontinence
Rationale:
Incontinence in a previously toilet-trained child can be a sign of a UTI. The infection can cause
irritation and a strong urge to urinate, leading to accidents.
7. A nurse on a pediatric unit is reviewing the laboratory results for a group of clients. Which of
the following results should the nurse prioritize?
a) An adolescent who has iron-deficiency anemia and Hgb level of 11 mg/dL.
b) A school-age child who has diabetes mellitus and an HbA1c of 8%.

c) A toddler who has moderate dehydration and an RBC count of 5.6/mm³.
d) A preschooler who has cystic fibrosis-related diabetes and WBC count of 15,000/mm³.
Answer: d) A preschooler who has cystic fibrosis-related diabetes and WBC count of
15,000/mm³.
Rationale:
A WBC count of 15,000/mm³ indicates a possible infection, which can be particularly serious for
a child with cystic fibrosis-related diabetes. This condition can complicate the management of
both the cystic fibrosis and diabetes, thus requiring immediate attention.
8. A nurse in a pediatric clinic is discussing the pathophysiology of Reye syndrome with a newly
licensed nurse. Which of the following statements by the newly licensed nurse indicates an
understanding of the disorder?
a) Reye syndrome causes fatty changes in the liver.
b) Reye syndrome leads to venous thrombus formation.
c) Reye syndrome is associated with misuse of acetaminophen.
d) Reye syndrome is linked to decreased serum ammonia level.
Answer: a) Reye syndrome causes fatty changes in the liver.
Rationale:
Reye syndrome is characterized by fatty changes in the liver and acute encephalopathy. It is
often associated with viral infections and the use of aspirin in children.
9. A nurse in a pediatric clinic is performing a history and physical for a toddler who is scheduled
to receive immunizations. Which of the following findings indicates that the immunization
should be withheld?
a) Temperature of 38°C (100.4°F).
b) Family history of sudden infant death syndrome (SIDS).
c) Taking an antihistamine for seasonal allergies.
d) Receiving prednisone for nephrotic syndrome.
Answer: d) Receiving prednisone for nephrotic syndrome.
Rationale:

Prednisone is an immunosuppressant, and receiving it can make the child more susceptible to
infection. Immunizations, especially live vaccines, should be postponed until the immune system
is not suppressed.
10. A nurse is teaching the parents of a toddler about strategies to manage temper tantrums.
Which of the following instructions should the nurse include in the teaching?
a) Honor the child’s request if she holds her breath.
b) Establish a structured daily routine for the child.
c) Place the child in her room alone until the temper tantrum ends.
d) Ignore the child's tantrums completely.
Answer: b) Establish a structured daily routine for the child.
Rationale:
Establishing a structured daily routine helps provide predictability and security for the toddler,
which can reduce the frequency and severity of temper tantrums. Honoring the child’s request
when they hold their breath can reinforce negative behavior, placing the child in a room alone
may not be safe, and ignoring tantrums may not address the underlying issues.
11. A nurse is assessing a child who has received the first 50 ml of a blood transfusion. Which of
the following findings should the nurse recognize as an indication the child may be experiencing
an air embolism?
a) Chills and fever
b) Sharp pain in middle of the chest
c) Severe headache
d) Sudden facial flushing
Answer: b) Sharp pain in middle of the chest
Rationale:
Sharp pain in the middle of the chest can indicate an air embolism, which is a serious
complication of a blood transfusion. This requires immediate intervention to prevent further
complications.

12. A nurse is instilling otic drops into an 18-month-old. Which of the following actions should
the nurse take?
a) Pull the pinna up and back
b) Pull the pinna down and back
c) Pull the pinna down and forward
d) Pull the pinna up and forward
Answer: b) Pull the pinna down and back
Rationale:
For children under 3 years old, the correct technique for administering otic drops is to pull the
pinna down and back to straighten the ear canal for proper instillation of the medication.
13. A charge nurse is assisting a newly licensed nurse with the preoperative assessment of a 2year-old child. Which of the following actions by the newly licensed nurse indicates an
understanding of the needed care?
a) Measuring the child’s abdominal circumference
b) Initiating NPO status 2 hours prior to surgery
c) Administering a cleansing enema
d) Giving the child a favorite toy for comfort
Answer: a) Measuring the child’s abdominal circumference
Rationale:
Measuring the child’s abdominal circumference can be crucial for certain types of surgeries,
especially those involving the abdomen, to monitor for potential distention or complications.
14. A nurse working on an outpatient surgical unit is providing discharge teaching to the parent
of a preschooler following the placement of tympanoplasty tubes. The parent asks the nurse,
“What should I do if the tubes fall out?” Which of the following responses should the nurse
make?
a) Gently put the tubes back into the child’s ears.
b) Bring the child to the emergency department immediately.
c) Notify the provider that the tubes have fallen out.
d) The tubes are sutured in place and must be surgically removed.

Answer: c) Notify the provider that the tubes have fallen out.
Rationale:
If tympanoplasty tubes fall out, the parent should notify the healthcare provider. The provider
will need to assess whether new tubes are necessary or if the ear has healed sufficiently.
15. A nurse is caring for a 4-month-old infant who is immediately postoperative following cleft
palate repair. Which of the following actions should the nurse take?
a) Give the infant liquids using a small spoon with a long handle.
b) Apply elbow restraints to the infant.
c) Gently check the infant’s suture line using a padded tongue depressor.
d) Place the infant in a supine position.
Answer: b) Apply elbow restraints to the infant.
Rationale:
Applying elbow restraints prevents the infant from touching or damaging the surgical site. This
is crucial for ensuring proper healing and preventing infection or dehiscence of the surgical
repair.
16. A nurse is caring for a child who is experiencing status asthmaticus. Which of the following
actions should the nurse take first?
a) Initiate an infusion of IV fluids.
b) Obtain a blood specimen for ABG analysis.
c) Administer a dose of an IV corticosteroid.
d) Apply humidified oxygen.
Answer: d) Apply humidified oxygen.
Rationale:
The first priority in managing status asthmaticus is to ensure adequate oxygenation. Applying
humidified oxygen helps to maintain oxygen saturation and can relieve bronchospasm.
17. A nurse is caring for a school-age child who has metastatic osteosarcoma. The child asks the
nurse, “Am I going to die?” Which of the following responses should the nurse make?
a) What is your pain level right now?

b) Your doctor will be able to answer your questions tomorrow.
c) It sounds like you are worried. Tell me what you have been told.
d) It’s natural to worry about death, but you should focus your energy on getting better.
Answer: c) It sounds like you are worried. Tell me what you have been told.
Rationale:
This response acknowledges the child's feelings and opens the door for further communication. It
allows the child to express their concerns and gives the nurse a better understanding of the
child’s knowledge and feelings about their condition.
18. A nurse is caring for an infant following a cleft lip and palate repair. Which of the following
actions should the nurse take during the postoperative period?
a) Encourage the use of a pacifier.
b) Provide hard toys.
c) Administer analgesic.
d) Perform oral suctioning frequently.
Answer: c) Administer analgesic.
Rationale:
Administering analgesics helps manage the infant's pain following surgery, promoting comfort
and facilitating healing. Using pacifiers or hard toys can damage the surgical site, and frequent
oral suctioning can irritate the sutures.
19. A nurse is providing dietary education to the mother of an infant. What recommendations
about the infant's diet should the nurse make? (Select all that apply.)
a) Solids can be introduced between 4 and 6 months of age.
b) Iron-fortified rice cereal should be offered first.
c) New foods should be introduced one at a time over a 5 to 7 day period to observe for allergies.
d) Vegetables or fruits are first started between 6 and 8 months of age.
e. Milk, eggs, wheat, citrus, peanut butter, and honey can be given after 6 months.
Answer: a) Solids can be introduced between 4 and 6 months of age.
b) Iron-fortified rice cereal should be offered first.
c) New foods should be introduced one at a time over a 5 to 7 day period to observe for allergies.

d) Vegetables or fruits are first started between 6 and 8 months of age.
Rationale:
These recommendations align with current guidelines for introducing solid foods to infants.
Introducing solids between 4 and 6 months, starting with iron-fortified rice cereal, and
introducing new foods one at a time help to identify any food allergies. Vegetables and fruits are
usually introduced between 6 and 8 months.
20. A nurse is caring for an infant who has a congenital heart defect. Which of the following
defects is associated with increased pulmonary blood flow?
a) Coarctation of the aorta.
b) Patent ductus arteriosus.
c) Tetralogy of Fallot.
d) Tricuspid atresia.
Answer: b) Patent ductus arteriosus.
Rationale:
Patent ductus arteriosus (PDA) is a condition in which the ductus arteriosus fails to close after
birth, leading to increased pulmonary blood flow. This can result in increased workload on the
heart and lungs.
21. A nurse is caring for a 6-month-old infant following surgery. Which of the following pain
assessment tools should the nurse use to assess the infant's pain?
a) FLACC pain scale
b) Oucher numeric scale
c) Wong-Baker faces pain rating scale
d) Visual analog scale (VAS)
Answer: a) FLACC pain scale
Rationale:
The FLACC (Face, Legs, Activity, Cry, Consolability) pain scale is appropriate for assessing
pain in infants and young children who are unable to verbally communicate their pain. It
provides a reliable and objective way to measure pain based on observed behaviors.