RN Comprehensive Predictor 2019 Form B
1. A nurse is providing teaching about the gastrostomy tube feedings to the parents of a school
age child. Which of the following instructions should the nurse take?
A. Administer the feeding over 30 min.
B. Place the child in as supine position after the feeding.
C. Charge the feeding bag and tubing every 3 days.
D. Warm the formula in the microwave prior to administration.
Answer: A. Administer the feeding over 30 min.
2. A nurse is administering digoxin 0.125 mg Po to an adult client. For which of the following
findings should the nurse report to the provider?
A. Potassium level 4.2 mEq/L.
B. Apical pulse 58/min.
C. Digoxin level 1 ng/ml.
D. Constipation for 2 days.
Answer: C. Digoxin level 1 ng/ml.
3. A nurse is caring for a client who is comatose and has advance directives that indicate the
client does not want life-sustaining measures. The client’s family want the client to have lifesustaining measures. Which of the following action should the nurse take?
A. Arrange for an ethics committee meeting to address the family’s concerns.
B. Support the family’s decision and initiate life-sustaining measures.
C. Complete an incident report.
D. Encourage the family to contact an attorney.
Answer: A. Arrange for an ethics committee meeting to address the family’s concerns.
4. A nurse is caring for a client who wears glasses. Which of the following actions should the
nurse take?
A. Store the glasses in a labeled case.
B. Clean the glasses with hot water.
C. Clean the glasses with a paper towel.
D. Store the glasses on the bedside table.
Answer: A. Store the glasses in a labeled case.
5. A nurse is teaching a group of newly licensed nurses about measures to take when caring for a
client who is on contact precautions. Which of the following should the nurse include in the
teaching?
A. Remove the protective gown after the client’s room.
B. Place the client in a room with negative pressure.
C. Wear gloves when providing care to the client.
D. Wear a mask when changing the linens in the client’s room.
Answer: C. Wear gloves when providing care to the client.
6. A nurse is planning on care for a client who is recovering from an acute myocardial infarction
that occurred 3 days ago. Which of the following instructions should the nurse include?
A. Perform an ECG every 12 hr.
B. Place the client in a supine position while resting.
C. Draw a troponin level every 4hr.
D. Obtain a cardiac rehabilitation consultation.
Answer: D. Obtain a cardiac rehabilitation consultation.
7. The nurse is reviewing the medical record of a client who is requesting combination oral
contraceptives. Which of the following conditions in the client’s history is a contradiction to the
use of oral contraceptives?
A. Hyperthyroidism.
B. Thrombophlebitis.
C. Diverticulosis.
D. Hypocalcemia.
Answer: B. Thrombophlebitis.
8. A nurse is caring for a client who request the creation of a living will. Which of the following
actions should the nurse take?
A. Schedule a meeting between the hospital ethics committee and the client.
B. Evaluate the client’s understanding of life-sustaining measures.
C. Determine the client’s preferences about post mortem care.
D. Request a conference with the client’s family.
Answer: B. Evaluate the client’s understanding of life-sustaining measures.
9. A nurse is caring for an adolescent who has sickle-cell anemia. Which of the following
manifestations indicates acute chest syndrome and should be immediately reported to the
provider?
A. Substernal retractions.
B. Hematuria.
C. Temperature 37.9 C (100.2 F).
D. Sneezing.
Answer: A. Substernal retractions.
10. A nurse is preforming a gastric lavage for a client who has upper gastrointestinal bleeding.
Which of the .following action should the nurse take?
A. Instill 500 ml of solution through the NG tube.
B. Insert a large-bore NG tube.
C. Use a cold irrigation solution.
D. Instruct the client to lie on his right side.
Answer: B. Insert a large-bore NG tube.
11. A nurse is providing care for a client who is in the advance stage of amyotrophic lateral
sclerosis. (ALS). Which of the following referrals is the nurse’s priority?
A. Psychologist.
B. Social worker.
C. Occupational therapist.
D. Speech-language pathologist.
Answer: D. Speech-language pathologist.
12. A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which of
the following findings should the nurse report to the provider?
A. WBC count 8,000/mm3.
B. Platelets 150,000/mm3.
C. Aspartate aminotransferase 10 units/L.
D. Erythrocyte sedimentation rate 75 mm/hr
Answer: D. Erythrocyte sedimentation rate 75 mm/hr
13. A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse
should expect a prescription for which of the following laboratory tests?
A. Platelet count.
B. Potassium level.
C. Creatine clearance.
D. Prealbumin.
Answer: A. Platelet count.
14. A nurse is caring for a client following application of a cast. Which of the following actions
should the nurse take first?
A. Place an ice pack over the cast.
B. Palpate the pulse distal to the cast.
C. Teach the client to keep the cast clean and dry.
D. Position the casted extremity on a pillow.
Answer: B. Palpate the pulse distal to the cast.
15. A nurse is caring for a client who has vision loss. Which of the following actions should the
nurse take? (Select all that apply)
A. Keep objects in the client’s room in the same place.
B. Ensure there is high-wattage lighting in the client’s room.
C. Approach the client from the side.
D. Allow extra time for the client to perform tasks.
E. Touch the client gently to announce presence.
Answer: A. Keep objects in the client’s room in the same place.
B. Ensure there is high-wattage lighting in the client’s room.
D. Allow extra time for the client to perform tasks.
16. A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has
questions about the disease. To research the nurse should identify that which of the following
electronic database has the most comprehensive collection of nursing (Unable to read) articles?
A. MEDLINE
B. CINAHL.
C. ProQuest.
D. Health Source.
Answer: B. CINAHL.
17. A nurse in an emergency department is assessing newly admitted client who is experiencing
drooling and hoarseness following a burn injury. Which of the following should actions should
the nurse take first?
A. Obtain a baseline ECG.
B. Obtain a blood specimen for ABG analysis.
C. Insert an 18-gauge IV catheter.
D. Administer 100% humidified oxygen.
Answer: D. Administer 100% humidified oxygen.
18. A nurse is planning care for a client who has unilateral paralysis and dysphagia following a
right hemispheric stroke. Which of the following interventions should the nurse include in the
plan?
A. Place food on the left side of the client’s mouth when he is ready to eat.
B. Provide total care in performing the client’s ADLs.
C. Maintain the client on bed rest.
D. Place the client’s left arm on a pillow while he is sitting.
Answer: D. Place the client’s left arm on a pillow while he is sitting.
19. A nurse is caring for a client who is in a seclusion room following violent behavior. The
client continues to display aggressive behavior. Which of the following actions should the nurse
take?
A. Confront the client about this behavior.
B. Express sympathy for the client’s situation.
C. Speak assertively to the client.
D. Stand within 30 cm (1 ft) of the client when speaking with them.
Answer: A. Confront the client about this behavior.
20. A nurse is caring for a client who is receiving brachytherapy for treatment of prostate cancer.
Which of the following actions should the nurse take?
A. Cleanse equipment before removal from the client’s room.
B. Limit the client’s visitors to 30 min per day.
C. Discard the client’s linens in a double bag.
D. Discard the radioactive source in a biohazard bag
Answer: B. Limit the client’s visitors to 30 min per day.
21. A nurse is assessing a client who has left-sided heart failure. Which of the following should
the nurse identify as a manifestation of pulmonary congestion?
A. Frothy, pink sputum.
B. Jugular vein distention.
C. Weight gain.
D. Bradypnea
Answer: D. Bradypnea
22. A nurse is caring for a client who is in labor and requires augmentation of labor. Which of the
following conditions should the nurse recognize as a contraindication to the use of oxytocin.
A. Diabetes mellitus.
B. Shoulder presentation.
C. Postterm with oligohydramnios. (I think Maternal Newborn Chapter 15 page 100)
D. Chorioamnionitis
Answer: C. Postterm with oligohydramnios. (I think Maternal Newborn Chapter 15 page 100)
23. A nurse is assessing a client who has left-sided heart failure. Which of the following should
the nurse identify as a manifestation of pulmonary congestion?
A. Frothy, pink sputum.
B. Jugular vein distention.
C. Weight gain.
D. Bradypnea
Answer: D. Bradypnea
24. A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and
a prescription for paternal fluid therapy. The guardian asks. “What are the indications that my
baby needs an IV?” Which of the following responses should the nurse make?
A. “Your baby needs an IV because she is not producing any tears”
B. “Your baby needs an IV because her fontanels are budging”
C. “Your baby needs an IV because she is breathing slower than normal”
D. “Your baby needs an IV because her heart rate is decreasing”
Answer: A. “Your baby needs an IV because she is not producing any tears”
25. A nurse is providing teaching to a client who has heart failure and a new prescription for
furosemide. Which of the following statements should the nurse make?
A. “Taking furosemide can cause your potassium levels to be high”
B. “Eat foods that are high in sodium”
C. “Rise slowly when getting out of bed”
D. “Taking furosemide can cause you to be overhydrated”
Answer: C. “Rise slowly when getting out of bed”
26. A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive
disorder. Which of the following interventions should the nurse take?
A. Allow the client enough time to perform rituals.
B. Give the client autonomy in scheduling activities.
C. Discourage the client from exploring irrational fears.
D. Provide negative reinforcement for ritualistic behaviors.
Answer: A. Allow the client enough time to perform rituals.
27. A nurse is caring for a client who has depression and reports taking ST. John’s wort along
with citalopram. The nurse should monitor the client for which of the following conditions as a
result of an interaction between these substances?
A. Serotonin syndrome
B. Tardive dyskinesia
C. Pseudo parkinsonism.
D. Acute dystonia.
Answer: A. Serotonin syndrome
28. A nurse is assessing a client who is receiving packed RBCs. Which of the following findings
indicate fluid overload?
A. Low back pain.
B. Dyspnea.
C. Hypotension.
D. Thready pulse.
Answer: B. Dyspnea.
29. A nurse is calculating a client’s expected date of delivery. The client’s last menstrual period
began on April. Using Nagele’s rule, what date should the nurse determine to be the client’s
expected delivery date? (Use mmdd format.)
A. 0119 date
B. 0220 date
C. 0330 date
D. 0428 date
Answer: A. 0119 date
30. A nurse is discussing group treatment and therapy with a client. The nurse should include
which of the following as being a characteristic of a therapeutic group?
A. The group is organized in an autocratic structure.
B. The group encourages members to focus on a particular issue. (Mental Health Chapter 8 Page
42)
C. The group must be led by a licensed psychiatrist.
D. The group encourages clients to form dependent relationships.
Answer: B. The group encourages members to focus on a particular issue. (Mental Health
Chapter 8 Page 42)
31. A nurse manger is reviewing documentation with a newly licensed nurse. Which of the
following notations by the newly licensed nurse indicates an understanding of the teaching.
UNSURE IF ON THE REPORT
A. “OOB with assistance for breakfast”
B. “Given 2 mg MSO4 IM for report of pain”
C. “Dressing changed qd”
D. “Administered 8 u regular insulin sq.”
Answer: D. “Administered 8 u regular insulin sq.”
32. A nurse is preparing to administer eye drops to a school-age child. Identify the actions the
nurse should take. (Move the steps into the box on the right, placing them in the order of
performance. Use all the steps.)
A. Apply pressure to the lacrimal punctum.
B. Ask the child to look upward.
C. Pull the lower eyelid downward.
D. Instill the drops of medication.
E. Place the child in a sitting position.
Answer: E, B, C, D, A
33. A nurse is caring for a client who speaks a language different from the nurse. Which of the
following should the nurse take?
A. Request an interpreter of a different sex from the client.
B. Request a family member or friend to interpret information for the client.
C. Direct attention toward the interpreter when speaking to the client.
D. Review the facility policy about the use of an interpreter.
Answer: D. Review the facility policy about the use of an interpreter.
34. A nurse is caring for a client who is in labor and is receiving oxytocin. Which of the
following findings indicates that the nurse should increase the rate of infusion?
ON THE REPORT needs double checking
A. Urine output 20 ml/hr.
B. Montevideo units constantly 300 mm Hg.
C. FHR pattern with absent variability.
D. Contractions every 5 min that last 30 seconds.
Answer: B. Montevideo units constantly 300 mm Hg.
35. A public health nurse is managing several projects for the community. Which of the
following interventions should the nurse identify as a primary prevention strategy?
A. Teaching parenting skills to expectant mothers and their partners.
B. Conducting mental health screenings at the local community center.
C. Referring client who have obesity to community exercise programs.
D. Providing crisis intervention through a mobile counseling unit.
Answer: A. Teaching parenting skills to expectant mothers and their partners.
36. A nurse is preparing to administer an autologous blood product to a client. Which of the
following actions should the nurse take to identify the client?
A. Match the client’s blood type with the type and cross match specimens.
B. Confirm the provider’s prescription matches the number on the blood component.
C. Ask the client to state the blood type and the date of their last blood donation.
D. Ensure that the client’s identification band matches the number on the blood unit.
Answer: A. Match the client’s blood type with the type and cross match specimens.
37. A nurse is performing physical therapy for a client who has Parkinson’s disease. Which of the
following statements by the client indicates the need for a referral to physical therapy?
A. “I have been experiencing more tremors in my left arm than before”
B. “I noticed that I am having a harder time holding on to my toothbrush”
C. “Lately, I feel like my feet are freezing up, as they are stuck to the ground”
D. “Sometimes, I feel I am making a chewing motion when I’m not eating”
Answer: C. “Lately, I feel like my feet are freezing up, as they are stuck to the ground”
38. A nurse is reviewing laboratory data for a client who has chronic kidney disease. Which of
the following findings should the nurse expect?
A. Increased creatine.
B. Increased hemoglobin.
C. Increased bicarbonate.
D. Increased calcium.
Answer: A. Increased creatine.
39. A nurse is administering a scheduled medication to a client. The client reports that the
medication appears different than what they take at home. Which of the following responses
should the nurse take?
A. “Did the doctor discuss with you that there was a change in this medication?”
B. “I recommend that you take this medication as prescribed”
C. “Do you know why this medication is being prescribed to you?”
D. “I will call the pharmacist now to check on this medication”
Answer: D. “I will call the pharmacist now to check on this medication”
40. A nurse is teaching at a community health fair about electrical fire prevention. Which of the
following information should the nurse include in the teaching?
A. Use three pronged grounded plugs.
B. Cover extension cords with a rug.
C. Check the tingling sensations around the cord to ensure the electricity is working.
D. Remove the plug from the socket by pulling the cord.
Answer: A. Use three pronged grounded plugs.
41. A charge nurse is recommending postpartum client discharge following a local disaster.
Which of the following should the nurse recommend for discharge?
A. A 42-year-old client who has preeclampsia and a BP of 166/110 mm Hg.
B. A 15-year-old client who delivered via emergency cesarean birth 1 day ago.
C. A client who received 2 units of packed RBCs 6 hr. ago for a postpartum hemorrhage.
D. A client who delivered precipitously 36 hr. ago and has a second-degree perineal laceration.
Answer: D. A client who delivered precipitously 36 hr. ago and has a second-degree perineal
laceration.
42. A nurse in a provider’s office is reviewing the laboratory results of a group of clients. Which
to report?
A. Herpes simplex.
B. Human papillomavirus
C. Candidiasis
D. Chlamydia
Answer: D. Chlamydia
43. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a
referral to a dietitian
A. A client who has a prescription for warfarin and states “I will need to limit how much spinach
I eat”.
B. A client who has gout and states, “I can continue to eat anchovies on my pizza.”
C. A client who has a prescription for spironolactone and states “I will reduce my intake of foods
that contain potassium”.
D. A client who has (Unable to read) and states “I’ll plan to take my calcium carbonate with a
full glass of water”.
Answer: B. A client who has gout and states, “I can continue to eat anchovies on my pizza.”
44. A nurse is preparing to measure a temperature of an infant. Which of the following action
should the nurse take?
A. Place the tip of the thermometer under the center of the infant’s axilla.
B. Pull the pinna of the infant’s ear forward before inserting the probe.
C. Insert the probe 3.8 cm (1.5in) into the infant’s rectum.
D. Insert the thermometer in front of the infant’s tongue.
Answer: A. Place the tip of the thermometer under the center of the infant’s axilla.
45. A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella rooster. Which
of the following information should the nurse include?
A. Children who have varicella are contagious until vesicles are crusted.
B. Children who have varicella should receive the herpes zoster vaccination.
C. Children who have varicella should be placed in droplet precaution.
D. Children who have varicella are contagious 4 days before the first vesicle eruption.
Answer: A. Children who have varicella are contagious until vesicles are crusted.
46. A nurse is reviewing the laboratory report of a client who has been having lithium carbonate
for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following
orders from the provider should the nurse expect?
A. Withhold the next dose.
B. Increase the dosage.
C. Discontinue the medication.
D. Administer the medication.
Answer: D. Administer the medication.
47. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of
the following medications should the nurse administer?
A. Pregabalin
B. Lorazepam
C. Colchicine
D. Codeine.
Answer: A. Pregabalin
48. A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the
following actions should the nurse take?
A. Prime IV tubing with 0.9% sodium chloride.
B. Use a 24-gauge IV catheter
C. Obtain filter less IV tubing.
D. Place blood in the warmer for 1 hr.
Answer: A. Prime IV tubing with 0.9% sodium chloride.
49. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the
following should the toddler participate?
A. Looking at alphabet flashcards.
B. Playing with a large plastic truck.
C. Use scissors cut out paper shapes.
D. Watching a cartoon in the dayroom.
Answer: B. Playing with a large plastic truck.
50. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary
recommendations should the nurse make?
A. Coffee with creamer.
B. Lettuce with sliced avocados.
C. Broiled skinless chicken breast with brown rice.
D. Warm toast with margarine.
Answer: C. Broiled skinless chicken breast with brown rice.
51. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should
the nurse plan to take?
A. Obtain the newborn’s body temperature using a tympanic thermometer.
B. (Unable to read) FACES pain scale.
C. Auscultate the newborn’s apical pulse for 60 seconds.
D. Measure the newborn’s head circumference over the eyebrows and below the occipital
prominence. (NOT)
Answer: C. Auscultate the newborn’s apical pulse for 60 seconds.
52. A nurse is caring for a client who is at 38 weeks gestation, is in active labor, and has ruptured
membrane. Which of the following actions should the nurse take?
A. Insert an indwelling urinary catheter.
B. Apply fetal heart rate monitor.
C. Initiate fundal massage.
D. Initiate an oxytocin IV infusion.
Answer: B. Apply fetal heart rate monitor.
53. A nurse is assessing a client who is 30 min postoperative following an arterial thrombectomy.
Which of the following findings should the nurse to report?
A. Chest pain
B. Muscle spasms.
C. Cool, moist skin.
D. Incisional pain.
Answer: A. Chest pain
54. A nurse is completing an incident report after a client fall. Which of the following
competencies of Quality and Safety Education for Nurse is the use demonstrating?
A. Quality improvement.
B. Patient (Unable to read)
C. Evidence based practice.
D. Informatics.
Answer: A. Quality improvement.
55. A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of
the following actions should the nurse take?
A. Confront the nurse about the suspected alcohol use.
B. Inform another nurse on the unit about the suspected alcohol use.
C. Ask the nurse to finish administering medications and then go home.
D. Notify the nursing manager about the suspected alcohol use.
Answer: D. Notify the nursing manager about the suspected alcohol use.
56. A nurse is caring for a client who has diaper dermatitis. Which of the following actions
should the nurse take?
A. Apply zinc oxide ointment to the irritated area.
B. (Unable to read)
C. Wipe stool from the skin using store bought baby wipes.
D. Apply talcum powder to the irritated area.
Answer: A. Apply zinc oxide ointment to the irritated area.
57. A nurse is reviewing the facility’s safety protocols considering newborn abduction with the
parent of a newborn. Which of the following statements indicates an understanding of the
teaching?
A. “Staff will apply identification band after first bath”
B. “I will not publish public announcement about my baby’s birth”
C. “I can remove my baby’s identification band as long as she is in my room”
D. “I can leave my baby in my room while I walk in the hallway”
Answer: B. “I will not publish public announcement about my baby’s birth”
58. A nurse is receiving a telephone prescription from a provider for a client who requires
additional medication for pain control. Which of the following entries should the nurse make in
the medical record?
A. “Morphine 3 mg SQ every 4 hr. PRN for pain.”
B. “Morphine 3 mg Subcutaneous (Unable to read)
C. “Morphine 3.0 mg sub q every 4 hr. PRN for pain.”
D. “Morphine 3 mg SC q 4 hr. PRN for pain.”
Answer: B. “Morphine 3 mg Subcutaneous (Unable to read)
59. A nurse realizes that the wrong medication has been administered to a client. Which of the
following actions should the nurse take first?
A. Notify the provider.
B. Report the incident to the nurse manager.
C. Monitor vital signs.
D. Fill out an incident report.
Answer: C. Monitor vital signs.
60. A nurse is providing teaching to a client who is experiencing preterm contractions and
dehydration. Which of the following statements should the nurse make?
A. “Dehydration is treated with calcium supplements”
B. “Dehydration can increase the risk of preterm labor”
C. “Dehydration associated gastroesophageal reflux”
D. “Dehydration is caused by a decreased hemoglobin and hematocrit”
Answer: B. “Dehydration can increase the risk of preterm labor”
61. A nurse is receiving a change-of-shift report for an adult female client who is postoperative.
Which of the following client information should the nurse report?
A. (Unable to read)
B. (Unable to read)
C. Answer might be lower platelets.
D. (Unable to read)
Answer: C. Answer might be lower platelets.
62. A nurse manager is developing a protocol for an urgent care clinic that often cares for clients
who do not speak the same language as clinical staff. Which of the following instructions should
the nurse include?
A. Use the client’s children to provide interpretation.
B. (Answer was the nurse was going to do the interpretation)
C. Offer client’s translation services for a nominal fee.
D. Evaluate the clients’ understanding at regular intervals.
Answer: B. (Answer was the nurse was going to do the interpretation)
63. A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing.
Which of the following examples should the nurse include in the teaching?
A. Leaving a nasogastric tube clamped after administering oral medication
B. Documenting communication with a provider in the progress notes of the client's medical
record
C. Administering potassium via IV bolus
D. Placing a yellow bracelet on a client who is at risk for falls
Answer: C. Administering potassium via IV bolus
64. A nurse is providing discharge teaching to a client who has a new prescription for phenelzine.
The nurse should instruct the client that it is safe to eat which of the following foods while taking
this medication?
A. Whole grain bread
B. Avocados
C. Smoked salmon
D. Pepperoni pizza
Answer: A. Whole grain bread
65. A nurse manager is updating protocols for the use of belt restraints. Which of the following
guidelines should the nurse include?
A. Attach the restraint to the bed's side rails.
B. Request a PRN restraint prescription for clients who are aggressive.
C. Document the client's condition every 15 min.
D. Remove the client's restraint every 4 hr.
Answer: C. Document the client's condition every 15 min.
66. A charge nurse on a medical-surgical unit is assisting with the emergency response plan
following an external disaster in the community. In anticipation of multiple client admissions,
which of the following current clients should the nurse recommend for early discharge?
A. A client who has COPD and a respiratory rate of 44/min
B. A client who has cancer with a sealed implant for radiation therapy
C. A client who is receiving heparin for deep-vein thrombosis
D. A client who is 1 day postoperative following a vertebroplasty
Answer: D. A client who is 1 day postoperative following a vertebroplasty
67. A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to
report to the provider. Which of the following findings should the nurse include in the teaching?
A. Bleeding gums
B. Faintness upon rising
C. Swelling of the face
D. Urinary frequency
Answer: C. Swelling of the face
68. A nurse is developing a plan of care for a client who has schizophrenia and is experiencing
auditory hallucinations. Which of the following actions should the nurse include in the plan?
A. Ask the client directly what he is hearing.
B. Encourage the client to lie down in a quiet room.
C. Avoid eye contact with the client.
D. Refer to the hallucinations as if they are real.
Answer: A. Ask the client directly what he is hearing.
69. A nurse is preparing to perform a sterile wound irrigation and dressing change for a client.
Which of the following actions by the nurse indicates a break in surgical aseptic technique?
A. Applying a sterile gown after applying a sterile mask
B. Balancing the bottle on the sterile basin while pouring the liquid
C. Placing the supplies on the sterile field and leaving a 1-inch perimeter
D. Putting on sterile gloves after preparing the sterile field
Answer: B. Balancing the bottle on the sterile basin while pouring the liquid
70. A nurse is teaching a prenatal class about infection prevention at a community center. Which
of the following statements by a client indicates an understanding of the teaching?
A. “I can visit my nephew who has chickenpox 5 days after the sores have crusted.”
B. “I can clean my cat's litter box during my pregnancy.”
C. “I should take antibiotics when I have a virus.”
D. “I should wash my hands for 10 seconds with hot water after working in the garden.”
Answer: A. “I can visit my nephew who has chickenpox 5 days after the sores have crusted.”
71. A nurse is planning care for a group of clients and is working with one licensed practical
nurse (LPN) and one assistive personnel (AP). Which of the following actions should the nurse
take first to manage her time effectively?
A. Develop an hourly time frame for tasks.
B. Schedule daily activities.
C. Determine goals of the day.
D. Delegate tasks to the AP.
Answer: C. Determine goals of the day.
72. A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the
following statements by the client indicates an understanding of the teaching?
A. “I will decrease my daily protein intake to 15 grams per day.”
B. “I will use ibuprofen as needed to control abdominal pain.”
C. “I will take sucralfate with meals three times per day.”
D. “I will avoid food and beverages that contain caffeine.”
Answer: D. “I will avoid food and beverages that contain caffeine.”
73. A nurse is reviewing legal issues in health care with a group of newly licensed nurses. Which
of the following recommendations should the nurse make?
A. Place copies of incident reports in clients’ medical records.
B. Overestimate clients’ acuity to prevent short staffing.
C. Ensure that each client has a living will on file prior to treatment.
D. Obtain personal professional liability insurance coverage.
Answer: C. Ensure that each client has a living will on file prior to treatment.
74. A nurse is providing preoperative teaching about patient-controlled analgesia (PCA) to a
client. Which of the following statements should the nurse include in the teaching?
A. “The PCA will deliver a double dose of medication when you push the button twice.”
B. “You can adjust the amount of pain medication you receive by pushing on the keypad.”
C. “Continuous PCA infusion is designed to allow fluctuating plasma medication levels.”
D. “You should push the button before physical activity to allow maximum pain control.”
Answer: D. “You should push the button before physical activity to allow maximum pain
control.”
75. A charge nurse is teaching a newly licensed nurse about clients designating a health care
proxy in situations that require a durable power of attorney for health care (DPAHC). Which of
the following information should the charge nurse include?
A. “The proxy should make health care decisions for the client regardless of the client's ability to
do so.”
B. “The proxy can make financial decisions if the need arises.”
C. “The proxy can make treatment decisions if the client is under anesthesia.”
D. “The proxy should manage legal issues for the client.”
Answer: C. “The proxy can make treatment decisions if the client is under anesthesia.”
76. A nurse is caring for a client who has a history of depression and is experiencing a situational
crisis. Which of the following actions should the nurse take first?
A. Confirm the client's perception of the event.
B. Notify the client's support person.
C. Help the client identify personal strengths.
D. Teach the client relaxation techniques.
Answer: A. Confirm the client's perception of the event.
77. A nurse is caring for a client who has end-stage kidney disease. The client's adult child asks
the nurse about becoming a living kidney donor for her father. Which of the following conditions
in the child's medical history should the nurse identify as a contraindication to the procedure?
A. Amputation
B. Osteoarthritis
C. Hypertension
D. Primary glaucoma
Answer: C. Hypertension
78. A nurse is planning care for a client who has bipolar disorder and is experiencing mania.
Which of the following interventions should the nurse include in the plan?
A. Encourage the client to spend time in the day room.
B. Withdraw the client's TV privileges if he does not attend group therapy.
C. Encourage the client to take frequent rest periods.
D. Place the client in seclusion when he exhibits signs of anxiety.
Answer: C. Encourage the client to take frequent rest periods.
79. A nurse is working with a client who has an anxiety disorder and is in the orientation phase of
the therapeutic relationship. Which of the following statements should the nurse make during this
phase?
A. “Let's talk about how you can change your response to stress.”
B. “We should establish our roles in the initial session.”
C. “Let me show you simple relaxation exercises to manage stress.”
D. “We should discuss resources to implement in your daily life.”
Answer: B. “We should establish our roles in the initial session.”
80. A staff education nurse is evaluating a group of nurses during a new employee orientation on
the use of proper body mechanics when lifting. Which of the following images indicates the
appropriate use of ergonomic principles?
A.
B.
C.
D.
Answer: C
81. A nurse is providing teaching to an older adult client about methods to promote nighttime
sleep. Which of the following instructions should the nurse include?
A. Stay in bed at least 1 hr if unable to fall asleep.
B. Take a 1 hr nap during the day.
C. Perform exercises prior to bedtime.
D. Eat a light snack before bedtime.
Answer: D. Eat a light snack before bedtime.
82. A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar
disorder. The partner states, “I don't know what to do. Everything has been happening so
quickly.” Which of the following responses by the nurse is therapeutic?
A. “Can you talk about what was happening with your partner at home?”
B. “Why do you think your partner's symptoms are progressing so quickly?”
C. “You should make sure your partner takes the prescribed medication.”
D. “You did the right thing by bringing your partner in for treatment.”
Answer: A. “Can you talk about what was happening with your partner at home?”
83. A nurse is receiving change-of-shift report for a group of clients. Which of the following
clients should the nurse plan to assess first?
A. A client who has sinus arrhythmia and is receiving cardiac monitoring
B. A client who has a hip fracture and a new onset of tachypnea
C. A client who has epidural analgesia and weakness in the lower extremities
D. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%
Answer: B. A client who has a hip fracture and a new onset of tachypnea
84. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel
syndrome. Which of the following recommendations should the nurse include?
A. Consume food high in bran fiber.
B. Increase intake of milk products.
C. Sweeten foods with fructose corn syrup.
D. Increase intake of foods high in gluten.
Answer: A. Consume food high in bran fiber.
85. A nurse is caring for an infant who has coarctation of the aorta. Which of the following
should the nurse identify as an expected finding?
A. Weak femoral pulses
B. Frequent nosebleeds
C. Upper extremity hypotension
D. Increased intracranial pressure
Answer: A. Weak femoral pulses
86. A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the
following adverse effects should the nurse include?
A. Excessive sweating
B. Increased urinary frequency
C. Dry cough
D. Metallic taste in mouth
Answer: A. Excessive sweating
87. A nurse is caring for a client who is in active labor and notes the FHR baseline has been
100/min for the past 15 min. The nurse should identify which of the following conditions as a
possible cause of fetal bradycardia?
A. Maternal fever
B. Fetal anemia
C. Maternal hypoglycemia
D. Chorioamnionitis
Answer: C. Maternal hypoglycemia
88. A nurse is providing teaching to the parents of a newborn about newborn genetic screening.
Which of the following statements should the nurse include in the teaching?
A. “This test should be performed after your baby is 24 hours old.”
B. “A nurse will draw blood from your baby's inner elbow.”
C. “Your baby will be given 2 ounces of water to drink prior to the test.”
D. “This test will be repeated when your baby is 2 months old.”
Answer: A. “This test should be performed after your baby is 24 hours old.”
89. A nurse is caring for a client who asks for information regarding organ donation. Which of
the following responses should the nurse make?
A. “I cannot be a witness for your consent to donate.”
B. “Your name cannot be removed once you are listed on the organ donor list.”
C. “Your desire to be an organ donor must be documented in writing.”
D. “You must be at least 21 years of age to become an organ donor.”
Answer: C. “Your desire to be an organ donor must be documented in writing.”
90. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The
nurse should monitor the client for which of the following complications?
A. Vomiting
B. Hypertension
C. Epigastric pain
D. Contractions
Answer: D. Contractions
91. A nurse is providing discharge teaching to a client who has chronic kidney disease and is
receiving hemodialysis. Which of the following instructions should the nurse include in the
teaching?
A. Take magnesium hydroxide for indigestior.
B. Drink at least 3 L of fluid daily.
C. Eat 1 g/kg of protein per day.
D. Consume foods high in potassium.
Answer: C. Eat 1 g/kg of protein per day.
92. A charge nurse is teaching new staff members about factors that increase a client's risk to
become violent. Which of the following risk factors should the nurse include as the best predictor
of future violence?
A. Previous violent behavior
B. A history of being in prison
C. Experiencing delusions
D. Male gender
Answer: A. Previous violent behavior
93. A nurse is teaching a client who is trying to conceive. Which of the following should the
nurse instruct the client to increase in her diet to prevent a neural tube defect?
A. Folate
B. Zinc
C. Iron
D. Calcium
Answer: A. Folate
94. A nurse is caring for a client who is experiencing acute mania. Which of the following foods
should the nurse provide for this client?
A. Peanut butter sandwich
B. Oatmeal with butter
C. Chicken noodle soup
D. Celery sticks
Answer: A. Peanut butter sandwich
95. A nurse is preparing to administer an IV medication to a client and accidently punctures the
IV bag causing the medication to leak on the counter. Which of the following medications
requires the nurse to follow facility procedures in the safe handling of a biohazardous material
spill?
A. Doxorubicin hydrochloride
B. Ampicillin sodium
C. Metronidazole
D. Phenytoin
Answer: A. Doxorubicin hydrochloride
96. A nurse in a provider's office is reviewing a female client's medical record during a routine
visit. The nurse should recommend increased dietary intake of which of the following vitamins?
(Click on the “Exhibit” button for additional information about the client. There are three tabs
that contain separate categories of data.)
A. Vitamin D
B. Vitamin K
C. Vitamin B12
D. Vitamin A
Answer: C. Vitamin B12
97. A nurse is developing an in-service about personality disorders. Which of the following
information should the nurse include when discussing borderline personality disorder?
A. “The client might act seductively.”
B. “The client is overly concerned about minor details.”
C. “The client exhibits impulsive behavior.”
D. “The client is exceptionally clingy to others.”
Answer: C. “The client exhibits impulsive behavior.”
98. A nurse is completing an admission assessment for a client who has narcissistic personality
disorder. Which of the following findings should the nurse expect?
A. Ritualistic behavior
B. Suspicious of others
C. Exhibits separation anxiety
D. Preoccupied with aging
Answer: D. Preoccupied with aging
99. A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of
the following actions should the nurse take?
A. Hold hand flat to perform percussions on the child.
B. Perform the procedure twice a day.
C. Administer a bronchodilator after the procedure.
D. Perform the procedure prior to meals.
Answer: D. Perform the procedure prior to meals.
100. A nurse is reviewing the medical record of a client who has schizophrenia and is taking
clozapine. Which of the following findings should the nurse identify as a contraindication to the
administration of clozapine?
A. Heart rate 58/min
B. Fasting blood glucose 100 mg/dL
C. Hgb 14 g/dL
D. WBC count 2,900/mm3
Answer: D. WBC count 2,900/mm3
101. A nurse is providing teaching about digoxin administration to the parents of a toddler who
has heart failure. Which of the following statements should the nurse include in the teaching?
A. “Limit your child's potassium intake while she is taking this medication.”
B. “You can add the medication to a half-cup of your child's favorite juice.”
C. “Repeat the dose if your child vomits within 1 hour after taking the medication.”
D. “Have your child drink a small glass of water after swallowing the medication.”
Answer: D. “Have your child drink a small glass of water after swallowing the medication.”
102. A school nurse is teaching a parent about absence seizures. Which of the following
information should the nurse include?
A. “This type of seizure can be mistaken for daydreaming.”
B. “This type of seizure lasts 30 to 60 seconds.”
C. “The child usually has an aura prior to onset.”
D. “This type of seizure has a gradual onset.”“
Answer: A. “This type of seizure can be mistaken for daydreaming.”
103. A nurse is reviewing assessment data from several clients. For which of the following
clients should the nurse recommend referral to a dietitian?
A. An older adult client who has a BMI of 24
B. A client who has a nonhealing leg ulcer
C. An older adult client who has presbyopia
D. A client who has an albumin level of 3.7 g/dL
Answer: B. A client who has a nonhealing leg ulcer
104. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of
the following places the client at risk for aspiration?
A. Sitting in a high-Fowler's position during the feeding
B. A history of gastroesophageal reflux disease
C. Receiving a high osmolarity formula
D. A residual of 65 mL 1 hr postprandial
Answer: B. A history of gastroesophageal reflux disease
105. A nurse is caring for several clients on a medical-surgical unit. For which of the following
nursing activities is it required that the nurse use sterile gloves?
A. Inserting an NG tube
B. Administering total parenteral nutrition through a central venous access device
C. Initiating IV access
D. Performing tracheostomy care
Answer: D. Performing tracheostomy care
106. A nurse is providing teaching to the parents of a newborn about newborn genetic screening.
Which of the following statements should the nurse include in the teaching?
A. “This test should be performed after your baby is 24 hours old.”
B. “A nurse will draw blood from your baby's inner elbow.”
C. “Your baby will be given 2 ounces of water to drink prior to the test.”
D. “This test will be repeated when your baby is 2 months old.”
Answer: A. “This test should be performed after your baby is 24 hours old.”
107. A nurse in a mental health clinic receives a request from a client who is undergoing
psychotherapy to obtain a copy of the therapist's notes. Which of the following responses should
the nurse make?
A. “We can provide a copy of your records, but the therapist's notes are not included.”
B. “I don't think you will benefit from reviewing your therapist's notes right now.”
C. “Why are you interested in seeing your therapist's notes?”
D. “Are you not happy with your treatment?”
Answer: A. “We can provide a copy of your records, but the therapist's notes are not included.”
108. A nurse is developing a plan of care for a client who has preeclampsia and is to receive
magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse
include in the plan?
A. Monitor the FHR via Doppler every 30 min.
B. Restrict the client's total fluid intake to 250 mL/hr.
C. Give the client protamine if signs of magnesium sulfate toxicity occur.
D. Measure the client’s urine output every hour.
Answer: D. Measure the client’s urine output every hour.
109. A nurse is assessing a client who is in active labor. Which of the following findings should
the nurse report to the provider?
A. Contractions lasting 80 seconds
B. FHR baseline 170/min
C. Early decelerations in the FHR
D. Temperature 37.4° C (99.3° F)
Answer: B. FHR baseline 170/min
110. A nurse is caring for a client who is in labor and has received an epidural. Which of the
following actions should the nurse take?
A. Decrease the maintenance infusion rate of IV fluid.
B. Have protamine sulfate available at the bedside.
C. Reposition the client side-to-side each hour.
D. Monitor the client for hypertension.
Answer: C. Reposition the client side-to-side each hour.
111. A nurse is building a therapeutic relationship with a newly admitted client. Which of the
following actions should the nurse plan to take during the orientation phase of the relationship?
A. Determine previous coping skills used by the client.
B. Establish the responsibilities of the nurse and client.
C. Facilitate the client's problem-solving skills.
D. Assist the client in expressing alternative behaviors.
Answer: B. Establish the responsibilities of the nurse and client.
112. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel
syndrome. Which of the following recommendations should the nurse include?
A. Increase intake of foods high in gluten.
B. Increase intake of milk products
C. Sweeten foods with fructose corn syrup.
D. Consume food high in bran fiber.
Answer: D. Consume food high in bran fiber.
113. A nurse is reviewing the medical records of four clients. The nurse should identify that
which of the following client findings requires follow up care?
A. A client who received a Mantoux test 48 hr ago and has an induration
B. A client who is scheduled for a colonoscopy and is taking sodium phosphate
C. A client who is taking warfarin and has an INR of 1.8
D. A client who is taking bumetanide and has a potassium level of 3.6 mEq/L
Answer: C. A client who is taking warfarin and has an INR of 1.8
114. A nurse is caring for a client who is 2 hr postoperative following a cardiac catheterization.
Which of the following is the priority assessment finding?
A. Report of burning sensation at the insertion site
B. Absence of pedal pulse in the affected extremity
C. Urinary output 25 mL/hr
D. Oxygen saturation 91%
Answer: B. Absence of pedal pulse in the affected extremity
115. A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of
the following actions should the nurse take?
A. Hold hand flat to perform percussions on the child.
B. Perform the procedure twice a day.
C. Perform the procedure prior to meals.
D. Administer a bronchodilator after the procedure.
Answer: C. Perform the procedure prior to meals.
116. A nurse in a mental health facility receives change-of-shift report for four clients. Which of
the following clients should the nurse plan to assess first?
A. A client placed in restraints due to aggressive behavior
B. A client who will be receiving her first ECT treatment today
C. A client who received a PRN dose of haloperidol 2 hr ago for increased anxiety
D. A newly admitted client who has a history of 4.5 kg (10 lb) weight loss in the past 2 months
Answer: A. A client placed in restraints due to aggressive behavior
117. A nurse is providing discharge teaching about car seat safety to a parent of a newborn.
Which of the following statements by the parent indicates an understanding of the teaching?
A. “I can turn my baby's car seat around when she weighs 15 pounds.”
B. “I can place my baby in the front seat with the airbag turned off.”
C. “I will place my baby in a forward-facing car seat in my back seat.”
D. “I will position my baby at a 45-degree angle in the car seat.”
Answer: D. “I will position my baby at a 45-degree angle in the car seat.”
118. A nurse in a clinic is assessing a 6-month-old infant. Which of the following findings should
the nurse report to the provider?
A. Pulse 140/min
B. Closed anterior fontanel
C. Respiratory rate 26/min
D. Abdominal breathing
Answer: B. Closed anterior fontanel
119. A nurse is planning care for a client who has bipolar disorder and is experiencing mania.
Which of the following interventions should the nurse include in the plan?
A. Encourage the client to spend time In the day room.
B. Place the client in seclusion when he exhibits signs of anxiety.
C. Withdraw the client's TV privileges if he does not attend group therapy.
D. Encourage the client to take frequent rest periods.
Answer: D. Encourage the client to take frequent rest periods.
120. A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the
following adverse effects should the nurse include?
A. Metallic taste in mouth
B. Dry cough
C. Increased urinary frequency
D. Excessive sweating
Answer: D. Excessive sweating
121. A nurse is developing an in-service about personality disorders. Which of the following
information should the nurse include when discussing borderline personality disorder?
A. “The client exhibits impulsive behavior.”
B. “The client might act seductively.”
C. “The client is exceptionally clingy to others.”
D. “The client is overly concerned about minor details.”
Answer: A. “The client exhibits impulsive behavior.”
122. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of
the following places the client at risk for aspiration?
A. A residual of 65 mL 1 hr postprandial
B. Sitting in a high-Fowler's position during the feeding
C. A history of gastroesophageal reflux disease
D. Receiving a high osmolarity formula
Answer: C. A history of gastroesophageal reflux disease
123. A nurse is caring for a client following a cardiac catheterization through the left groin.
Which of the following actions should the nurse take?
A. Monitor the dorsalis pedis pulse every 15 min.
B. Keep the client NPO for 24 hr.
C. Place the client in Fowler's position.
D. Maintain strict bedrest for the first 12 hr.
Answer: A. Monitor the dorsalis pedis pulse every 15 min.
124. A nurse is reviewing the medical record of a client who has a prescription for intermittent
heat therapy for a foot injury. Which of the following findings should the nurse identify as a
contraindication for heat therapy?
A. Peripheral neuropathy
B. Osteoarthritis
C. Abdominal aortic aneurysm
D. Phlebitis
Answer: A. Peripheral neuropathy
125. A nurse in an emergency department is caring for a toddler who has burns following a house
fire. Which of the following actions should the nurse take first?
A. Calculate fluid replacement based on vital signs and urinary output.
B. Determine the location and depth of the burns.
C. Check the mouth for soot and smoky breath.
D. Administer antibiotics prophylactically to prevent sepsis.
Answer: C. Check the mouth for soot and smoky breath.
126. A nurse is caring for a client following a stroke. The client has right-sided weakness and
facial drooping. Which of the following nursing actions is the priority?
A. Perform range-of-motion exercises to the client's extremities.
B. Place the client’s right hand in a supination position.
C. Change the client's position every 2 hr.
D. Maintain NPO status for the client.
Answer: D. Maintain NPO status for the client.
127. A nurse is caring for an adult client who has chronic anemia and is scheduled to receive a
transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take?
A. Administer the blood via a 21-gauge IV needle.
B. Set the IV infusion pump to administer the blood over 6 hr.
C. Check the client’s vital signs from the previous shift prior to the initiation of the transfusion.
D. Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion.
Answer: D. Flush the blood administration tubing with 0.9% sodium chloride prior to the
transfusion.
128. Intradermal Injection areas
A. Buttocks.
B. Upper back.
C. Hamstring area.
D. Arms
Answer: B. Upper back.
129. A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the
following are expected findings? (Select all that apply.)
A. Impulse control difficulty
B. Left hemiplegia
C. Loss of depth perception
D. Aphasia
E. Lack of situational awareness
Answer: A. Impulse control difficulty
B. Left hemiplegia
C. Loss of depth perception
E. Lack of situational awareness
130. A nurse is caring for a client who has left homonymous hemianopsia. Which of the
following is an appropriate nursing intervention?
A. Teach the client to scan the right to see objects on the right side of her body.
B. Place the bedside table on the right side of the bed.
C. Orient the client to the food on her plate using the clock method.
D. Place the wheelchair on the client’s left side.
Answer: B. Place the bedside table on the right side of the bed.
131. A nurse is planning care for a client who has dysphagia and a new dietary prescription.
Which of the following should the nurse include in the plan of care? (Select all that apply.)
A. Have suction equipment available for use.
B. Feed the client thickened liquids.
C. Place food on the unaffected side of the client’s mouth.
D. Assign an assistive personnel to feed the client slowly.
E. Teach the client to swallow with her neck flexed.
Answer: A. Have suction equipment available for use.
B. Feed the client thickened liquids.
C. Place food on the unaffected side of the client’s mouth.
E. Teach the client to swallow with her neck flexed.
132. A nurse is caring for a client who has global aphasia (both receptive and expressive.). Which
of the following should the nurse include in the client’s plan of care? (Select all that apply.)
A. Speak to the client at a slower rate.
B. Assist the client to use flash cards with pictures.
C. Speak to the client in a loud voice.
D. Complete sentences that the client cannot finish.
E. Give instructions one step at a time.
Answer: A. Speak to the client at a slower rate.
B. Assist the client to use flash cards with pictures.
E. Give instructions one step at a time.
133. A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the
following is an expected finding?
A. Impulse control difficulty
B. Poor judgement
C. Inability to recognize familiar objects
D. Loss of depth perception
Answer: C. Inability to recognize familiar objects
134. A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure,
which of the following actions should the nurse take?
A. Position the client in an upright position, leaning over the bedside table.
B. Explain the procedure.
C. Obtain ABG’s.
D. Administer benzocaine spray.
Answer: A. Position the client in an upright position, leaning over the bedside table.
135. A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The
results are pH 7.47, PaCo2 32 mm Hg. HCO3 22 mm Hg. The nurse should recognize that the
client is experiencing which of the following acid-base imbalances?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
Answer: B. Respiratory alkalosis
136. A nurse is assessing a client following bronchoscopy. Which of the following findings
should the nurse report to the provider?
A. Blood-tinged sputum
B. Dry, nonproductive cough
C. Sore throat
D. Bronchospasms
Answer: D. Bronchospasms
137. A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following
supplies should the nurse ensure are in the client’s room? (Select all that apply.)
A. Oxygen equipment
B. Incentive spirometer
C. Pulse oximeter
D. Sterile dressing
E. Suture removal kit
Answer: A. Oxygen equipment
C. Pulse oximeter
D. Sterile dressing
138. A nurse is caring for a client following a thoracentesis. Which of the following
manifestations should the nurse recognize as risks for complications? (Select all that apply.)
A. Dyspnea
B. Localized bloody drainage on the dressing
C. Fever
D. Hypotension
E. Report of pain at the puncture site
Answer: A. Dyspnea
C. Fever
D. Hypotension
139. A nurse is preparing to care for a client following chest tube placement. Which of the
following items should be available in the client’s room? (Select all that apply.)
A. Oxygen
B. Sterile water
C. Enclosed hemostat clamps
D. Indwelling urinary catheter
E. Occlusive dressing
Answer:
A. Oxygen
B. Sterile water
C. Enclosed hemostat clamps
E. Occlusive dressing
140. A nurse is caring for a client who has a chest tube and drainage system in place. The nurse
observes that the chest tube was accidentally removed. Which of the following actions should the
nurse take first?
A. Obtain a chest x-ray
B. Apply sterile gauze to the insertion site.
C. Place tape around the insertion site.
D. Assess respiratory status.
Answer: B. Apply sterile gauze to the insertion site.
141. A nurse is assessing a client who has a chest tube and drainage system in place. Which of
the following are expected findings? (Select all that apply.)
A. Continuous bubbling in the water seal chamber
B. Gentle constant bubbling in the suction control chamber
C. Rise and fall in the level of water in the water seal chamber with inspiration and expiration
D. Exposed sutures without dressing
E. Drainage system upright at chest level
Answer: B. Gentle constant bubbling in the suction control chamber
C. Rise and fall in the level of water in the water seal chamber with inspiration and expiration
142. A nurse is assisting a provider with the removal of a chest tube. Which of the following
should the nurse instruct the client to do?
A. Lie on it left side.
B. Use the incentive spirometer.
C. Cough at regular intervals.
D. Perform the Valsalva maneuver.
Answer: D. Perform the Valsalva maneuver.
143. A nurse is planning care for a client following the insertion of a chest tube and drainage
system. Which of the following should be included in the plan of care? (Select all that apply.)
A. Encourage the client to cough every 2 hours.
B. Check the continuous bubbling in the suction chamber.
C. Strip the drainage tubing every 4 hours.
D. Clamp the tube once a day.
E. Obtain a chest x-ray.
Answer: A. Encourage the client to cough every 2 hours.
B. Check the continuous bubbling in the suction chamber.
E. Obtain a chest x-ray.
144. A nurse is orientation a newly licensed nurse who is caring for a client who is receiving
mechanical ventilation and is receiving mechanical ventilation and is on pressure support
ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates
and understanding of PSV?
A. “It keeps the alveoli open and prevents atelectasis.”
B. “It allows preset pressure delivered during spontaneous ventilation.”
C. “It guarantees minimal minute ventilator.”
D. “It delivers a preset ventilatory rate and tidal volume to the client.”
Answer: B. “It allows preset pressure delivered during spontaneous ventilation.”
145. A nurse is caring for a client who is experiencing respiratory distress. Which of the
following early manifestations of hypoxemia should the nurse recognize? (Select all that apply.)
A. Confusion
B. Pale skin
C. Bradycardia
D. Hypotension
E. Elevation blood pressure.
Answer: B. Pale skin
E. Elevation blood pressure.
146. A nurse is orienting a newly licensed nurse on performing routine assessment of a client
who is receiving mechanical ventilation via an endotracheal tube. Which of the following
information should the nurse include in the teaching?
A. Apply a vest restraint if self-extubation is attempted.
B. Monitor ventilator settings ever 8 hours.
C. Document tube placement in centimeters at the angle of jaw.
D. Assess breath sounds every 1 to 2 hours.
Answer: D. Assess breath sounds every 1 to 2 hours.
147. A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which
of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to
the client?
A. Nonrebreather mask
B. Venturi mask
C. Nasal cannula
D. Simple face mask
Answer: B. Venturi mask
148. A nurse is planning care for a client who is receiving mechanical ventilation. Which of the
following modes of ventilation that increase the effort of the client’s respiratory muscles should
the nurse include in the plan of care? (Select all that apply.)
A. Assist-control
B. Synchronized intermittent mandatory ventilation
C. Continuous positive airway pressure
D. Pressure support ventilation
E. Independent lung ventilation
Answer: B. Synchronized intermittent mandatory ventilation
C. Continuous positive airway pressure
D. Pressure support ventilation
149. A nurse is monitoring a group of clients for increased risk for developing pneumonia.
Which of the following clients should the nurse expect to be at risk? (Select all that apply.)
A. Client who has dysphagia
B. Client who has AIDS
C. Client who was vaccinated for pneumococcus and influenza 6 months ago
D. Client who is postoperative and received local anesthesia.
E. Client who has a closed head injury and is receiving ventilation
F. Client who has myasthenia gravis
Answer: A. Client who has dysphagia
B. Client who has AIDS
E. Client who has a closed head injury and is receiving ventilation
F. Client who has myasthenia gravis
150. A nurse in a clinic is caring for a client whose partner states the client woke up this
morning, did not recognize him, and did not know where she was. The client reports chills and
chest pain that is worse upon inspiration. Which of the following actions is the nurse’s priority?
A. Obtain baseline vital signs and oxygen saturation.
B. Obtain a sputum culture.
C. Obtain a complete history from the client.
D. Provide a pneumococcal vaccine.
Answer: A. Obtain baseline vital signs and oxygen saturation.
151. A nurse is caring for a client who has pneumonia. Assessment findings include temperature
37.8 C (100 F), respirations 30/min, blood pressure 130/76, heart rate 100/min, and SaO2 91% on
room air. Prioritize the following nursing interventions.
A. Administer antibiotics.
B. Administer oxygen therapy.
C. Perform a sputum culture.
D. Administer an antipyretic medication to promote client comfort.
Answer:
A. Administer antibiotics. (3)
B. Administer oxygen therapy. (1)
C. Perform a sputum culture. (2)
D. Administer an antipyretic medication to promote client comfort. (4)
152. A nurse in a clinic is assessing a client who has sinusitis. Which of the following techniques
should the nurse use to identify manifestations of this disorder?
A. Percussion of posterior lobes of lungs
B. Auscultation of the trachea
C. Inspection of the conjunctiva
D. Palpation of the orbital areas
Answer: D. Palpation of the orbital areas
153. A nurse is teaching a group of clients about influenza. Which of the following client
statements indicates an understanding of the teaching?
A. “I should wash my hands after blowing my nose to prevent spreading the virus.”
B. “I need to avoid drinking fluids if I develop symptoms.”
C. “I need a flu shot every 2 years because of the different flu strains.”
D. “I should cover my mouth with my hand when I sneeze.”
Answer: A. “I should wash my hands after blowing my nose to prevent spreading the virus.”
154. A nurse in the emergency department is caring for a client who is having an acute asthma
attack. Which of the following assessments indicates that the respiratory status is declining?
(Select all that apply.)
A. SaO2 95%
B. Wheezing
C. Retraction of sternal muscles
D. Pink mucous membranes
E. Premature ventricular complexes (PVC’s)
Answer: B. Wheezing
C. Retraction of sternal muscles
E. Premature ventricular complexes (PVC’s)
155. A nurse is caring for a client 2 hours after admission. The client has an SaO 2 of 91%,
exhibits audible wheezes, and is using accessory muscles when breathing. Which of the
following classes of medication should the nurse expect to administer?
A. Antibiotic
B. Beta-blocker
C. Antiviral
D. Beta2 agonist
Answer: D. Beta2 agonist
156. A nurse is providing discharge teaching to a client who has a new prescription for
prednisone for asthma. Which of the following client statements indicates an understanding in
teaching?
A. “I will decrease my fluid intake while taking this medication.”
B. “I will expected to have black, tarry stools.”
C. “I will take my medication with meals.”
D. “I will monitor for weight loss while on this medication.”
Answer: C. “I will take my medication with meals.”
157. A nurse is assessing a client who has a history of asthma. Which of the following factors
should the nurse identify as a risk for asthma?
A. Gender
B. Environmental allergies
C. Alcohol use
D. Race
Answer: B. Environmental allergies
158. A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator.
Which of the following client statements indicates an understanding of the teaching?
A. “This medication can decrease my immune response.”
B. “I take this medication to prevent asthma attacks.”
C. “I need to take this medication with food.”
D. “This medication has a slow onset to treat my symptoms.”
Answer: B. “I take this medication to prevent asthma attacks.”
159. A nurse is providing discharge teaching to a client who has COPD and a new prescription
for albuterol. Which of the following statements by the client indicates and understanding of the
teaching?
A. “This medication can increase my blood sugar levels.”
B. “This medication can decrease my immune response.”
C. “I can have an increase in my heart rate while taking this medication.”
D. “I can have mouth sores while taking this medication.”
Answer: C. “I can have an increase in my heart rate while taking this medication.”
160. A nurse is preparing to administer a dose of a new prescription of prednisone to a client who
has COPD. The nurse should monitor for which of the following adverse effects of this
medication? (Select all that apply.)
A. Hypokalemia
B. Tachycardia
C. Fluid retention
D. Nausea
E. Black, tarry stools
Answer: A. Hypokalemia
C. Fluid retention
E. Black, tarry stools
161. A nurse is discharging a client who has COPD. Upon discharge, the client is concerned that
he will never be able to leave his house now that he is on continuous oxygen. Which of the
following is an appropriate response by the nurse?
A. “There are portable oxygen delivery systems that you can take with you.”
B. “When you go out, you can remove the oxygen and then reapply it when you get home.”
C. “You probably will not be able to go out at much as you used to.”
D. “Home health services will come to see you so you will not need to get out.”
Answer: A. “There are portable oxygen delivery systems that you can take with you.”
162. A nurse is instructing a client on the use of an incentive spirometer. Which of the following
statements by the client indicates an understanding of the teaching?
A. “I will place the adapter on my finger to read my blood oxygen saturation level.”
B. “I will lie on my back with my knees bent.”
C. “I will rest my hand over my abdomen to create resistance.”
D. “I will take in a deep breath and hold it before exhaling.”
Answer: D. “I will take in a deep breath and hold it before exhaling.”
163. A nurse is planning to instruct a client on how to perform pursed-lip breathing. Which of the
following should the nurse include in the plan of care?
A. Take quick breaths upon inhalation.
B. Place you hand over your stomach.
C. Take a deep breath in through your nose.
D. Puff your cheeks upon exhalation.
Answer: C. Take a deep breath in through your nose.
164. A home health nurse is teaching a client who has active tuberculosis. The provider has
prescribed the following medication regimen: isoniazid 250 mg PO daily, rifampin 500 mg PO
daily, pyrazinamide 750 mg PO daily, and ethambutol 1 mg PO daily. Which of the following
client statements indicate the client understands the teaching? (Select all that apply.)
A. “I can substitute one medication for another if I run out because that all fight infection.”
B. “I will wash my hands each time I cough.”
C. “I will wear a mask when I am in a public area.”
D. “I am glad I don’t have to have any more sputum specimens.”
E. “I don’t need to worry where I go once I start taking my medications.”
Answer: B. “I will wash my hands each time I cough.”
C. “I will wear a mask when I am in a public area.”
165. A nurse is teaching a client who has tuberculosis. Which of the following statements should
the nurse include in the teaching?
A. “You will need to continue to take the multi-medication regimen for 4 months.”
B. ”You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the
medication.”
C. “You will need to remain hospitalized for treatment.”
D. “You will need to wear a mask at all times.”
Answer: B. ”You will need to provide sputum samples every 4 weeks to monitor the
effectiveness of the medication.”
166. A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed
on a multi-medication regimen. Which of the following instructions should the nurse give the
client related to ethambutol?
A. “Your urine can turn a dark orange.”
B. “Watch for a change in the sclera of your eyes.”
C. “Watch for any changes in vision.”
D. “Take vitamin B6 daily.”
Answer: C. “Watch for any changes in vision.”
167. A nurse is preparing to administer a new prescription for isoniazid (INH) to a client who has
tuberculosis. The nurse should instruct the client to report which of the following findings as an
adverse effect of the medication?
A. “You might notice yellowing of your skin.”
B. “You might experience pain in your joints.”
C. “You might notice tingling of your hands.”
D. “You might experience loss of appetite.”
Answer: C. “You might notice tingling of your hands.”
168. A nurse is providing information about tuberculosis to a group of clients at a local
community center. Which of the following manifestations should the nurse include in the
teaching? (Select all that apply.)
A. Persistent cough
B. Weight gain
C. Fatigue
D. Night sweats
E. Purulent sputum
Answer: A. Persistent cough
C. Fatigue
D. Night sweats
E. Purulent sputum
169. A nurse is caring for a group of clients. Which of the following clients are at risk for
pulmonary embolism? (Select all that apply.)
A. A client who has a BMI of 30
B. A female client who is postmenopausal
C. A client who has a fractured femur
D. A client who is a marathon runner
E. A client who has chronic atrial fibrillation
Answer: A. A client who has a BMI of 30
C. A client who has a fractured femur
E. A client who has chronic atrial fibrillation
170. A nurse is assessing a client who has a pulmonary embolism. Which of the following
information should the nurse expect to find? (Select all that apply.)
A. Bradypnea
B. Pleural friction rub
C. Hypertension
D. Petechiae
E. Tachycardia
Answer: B. Pleural friction rub
D. Petechiae
E. Tachycardia
171. A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The
client states she is anxious and is unable to get enough air. Vital signs are HR 117/min,
respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. Which of
the following nursing actions is the priority?
A. Notify the provider.
B. Administer heparin via IV infusion.
C. Administer oxygen therapy.
D. Obtain a spiral CT scan.
Answer: C. Administer oxygen therapy.
172. A nurse is caring for a client who has a new prescription for heparin therapy. Which of the
following statements by the client should indicate and immediate concern for the nurse?
A. “I am allergic to morphine.”
B. “I take antacids several times a day.”
C. “I had a blood clot in my leg several years ago.”
D. “It hurts to take a deep breath.”
Answer: B. “I take antacids several times a day.”
173. A nurse is caring for a client who is to receive thrombolytic therapy. Which of the following
factors should the nurse recognize as a contraindication to the therapy?
A. Hip arthroplasty 2 weeks ago
B. Elevated sedimentation rate
C. Incident of exercise-induced asthma 1 week ago
D. Elevated platelet count
Answer: A. Hip arthroplasty 2 weeks ago
174. A nurse is assessing a client following a gunshot wound to the chest. For which of the
following findings should the nurse monitor to detect a pneumothorax? (Select all that apply.)
A. Tachypnea
B. Deviation of the trachea
C. Bradycardia
D. Decreased use of accessory muscles
E. Pleuritic pain
Answer: A. Tachypnea
B. Deviation of the trachea
E. Pleuritic pain
175. A nurse is reviewing the prescriptions for a client who has a pneumothorax. Which of the
following actions should the nurse perform first?
A. Assess the client’s pain.
B. Obtain a large-bore IV needle for decompression.
C. Administer lorazepam.
D. Prepare for chest tube insertion.
Answer: B. Obtain a large-bore IV needle for decompression.
176. A nurse is reviewing discharge instructions for a client who experienced a pneumothorax.
Which for the following statement should the nurse use when teaching the client?
A. “Notify the provider if you experience weakness.”
B. “You should be able to return to work in 1 week.”
C. “You need to wear a mask when in crowded areas.”
D. “Notify your provider if you experience a productive cough.”
Answer: D. “Notify your provider if you experience a productive cough.”
177. A nurse in the emergency department is assessing a client who has a suspected flail chest.
Which of the following findings should the nurse expect? (Select all that apply.)
A. Bradycardia
B. Cyanosis
C. Hypotension
D. Dyspnea
E. Paradoxic chest movement
Answer: B. Cyanosis
C. Hypotension
D. Dyspnea
E. Paradoxic chest movement
178. A nurse in the emergency department is assessing a client who was in a motor vehicle crash.
Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68
mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6 C (101.4 F), and SaO2 92% on
room air. Which of the following actions should the nurse take first?
A. Obtain a chest ex-ray.
B. Prepare for chest tube insertion.
C. Administer oxygen via high-flow mask.
D. Initiate IV access.
Answer: C. Administer oxygen via high-flow mask.
179. A nurse is orientation a newly licensed nurse on the purpose of administering vecuronium to
a client who has acute respiratory distress syndrome (ARDS). Which of the following statements
by the newly licensed nurse indicates understanding of the teaching?
A. “This medication is given to treat infection.”
B. “This medication is given to facilitate ventilation.”
C. “This medication is given to decrease inflammation.”
D. “This medication is given to reduce anxiety.”
Answer: B. “This medication is given to facilitate ventilation.”
180. A nurse is reviewing the health records of five clients. Which of the following clients are at
risk for developing acute respiratory distress syndrome? (Select all that apply.)
A. A client who experienced a near-drowning incident
B. A client following coronary artery bypass graft surgery
C. A client who has a hemoglobin of 15.1 mg/dL
D. A client who has dysphagia
E. A client who experienced a drug overdose
Answer: A. A client who experienced a near-drowning incident
B. A client following coronary artery bypass graft surgery
D. A client who has dysphagia
E. A client who experienced a drug overdose
181. A nurse is planning care for a client who has severe respiratory distress system (SARS).
Which of the following actions should be included in the plan of care for this client? (Select all
that apply.)
A. Administer antibiotics.
B. Provide supplemental oxygen.
C. Administer antiviral medications.
D. Administer bronchodilators.
E. Maintain ventilatory support.
Answer: B. Provide supplemental oxygen.
D. Administer bronchodilators.
E. Maintain ventilatory support.
182. A nurse is caring for a client who is receiving vecuronium for acute respiratory distress
syndrome. Which of the following medications should the nurse anticipate administering with
this medication? (Select all that apply.)
A. Fentanyl
B. Furosemide
C. Midazolam
D. Famotidine
E. Dexamethasone
Answer: A. Fentanyl
C. Midazolam
183. A nurse is orienting a newly licensed nurse on the care of a client who is to have a line
placed for hemodynamic monitoring. Which of the following statements by the newly licensed
nurse indicates effectiveness of the teaching?
A. “Air should be instilled into the monitoring system prior to the procedure.”
B. “The client should be positioned on the left side during the procedure.”
C. “The transducer should be level with the second intercostal spaced after the line is placed.”
D. “A chest x-ray is needed to verify placement after the procedure.”
Answer: D. “A chest x-ray is needed to verify placement after the procedure.”
