ATI RN PROCTORED COMPREHENSIVE PREDICTOR FORM A NUR 441
QUESTIONS WITH ANSWERS RATED A
A nurse is caring for a patient who is at 33 weeks of gestation following an amniocentesis. The
nurse should monitor the patient for which of the following complications?
A. Vomiting
B. Hypertension
C. Epigastric pain
D. Contractions
Answer: D. Contractions
A nurse is providing teaching to an older adult patient about methods to promote night time
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
A nurse on a telemetry unit is caring for a patient who becomes unconscious and whose
monitor displays ventricular tachycardia. Which of the following actions should the nurse take
first after determining the patient does not have a palpable pulse?
A. Assess heart sounds
B. Defibrillate
C. Establish IV access
D. Administer epinephrine
Answer: B. Defibrillate
A nurse is admitting a patient who 1 week postpartum and reports excessive vaginal bleeding.
The nurse does not speak the same language as the client. The client’s partner and 10-year-old
child are accompanying her. Which of the following actions should the nurse take to gather the
client’s admission data?
A. Have the client’s child translate
B. Allow the client’s partner to translate
C. Request a female interpreter through the facility
D. Ask a nursing student who speaks the same language as the patient to translate
Answer: C. Request a female interpreter through the facility
A nurse is caring for a patient who is febrile (High fever). To reduce the client’s fever, the
nurse applies a cooling blanket. Which of the following findings indicates the patient is having
an adverse reaction to the cooling?
A. Flushing
B. Tachycardia
C. Restlessness
D. Hyperthermia
Answer: C. Restlessness
A nurse is caring for a patient who has deep-vein-thrombosis of the left lower extremity. Which
of the following actions should the nurse take? (Exhibit)
A. Position the patient with the affected extremity lower than the heart
B. Withhold heparin IV infusion PTT- 30-40 seconds; x2 if on heparin
C. Administer acetaminophen
D. Massage the affected extremity every 4 hr
Answer: B. Withhold heparin IV infusion PTT- 30-40 seconds; x2 if on heparin
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 patient who has a BMI of 24 (18. 5-24. 9)
B. A patient who has a nonhealing leg ulcer (diet isn’t good)
C. An older adult patient who has presbyopia (age related far-sightness)
D. A patient who has an albumin level of 3. 7 g/dL (normal 3. 4-5. 4)
Answer: B. A patient who has a nonhealing leg ulcer (diet isn’t good)
A nurse is providing discharge teaching to a patient who has a chronic kidney disease and is
receiving hemodialysis. Which of the following instructions should the nurse include in the
teaching?
A. Eat 1 g/kg of protein per day
B. Take magnesium hydroxide for indigestion
C. Drink at least 3 L of fluid dailyD. Consume foods high in potassium- restrict
Answer: A. Eat 1 g/kg of protein per day
A nurse is caring for a patient who is receiving intermittent enteral tube feedings. Which of the
following places the patient 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
A nurse is providing prenatal teaching to a patient who is at 12 weeks of gestation. The nurse
should tell the patient that she will undergo which of the following screening tests at 16 weeks
of gestation?
A. Chorionic villus sampling- as early as 8 weeks
B. Cervical cultures for chlamydia- 1st appointment.
C. Nonstress test -28 weeks
D. Maternal serum alpha-fetoprotein- 16 to 18 weeks
Answer: D. Maternal serum alpha-fetoprotein- 16 to 18 weeks
A nurse is caring for a patient who is on bed rest. The nurse should recognize that which of the
following findings is a complication of immobility?
A. Decreased serum calcium levels- increased serum calcium
B. Increased blood pressure- hypotension
C. Swollen area on calf
D. Urinary frequencyAnswer: C. Swollen area on calf
A nurse in acute care mental health facility is participating in a medication- education group.
The leader of the group uses a laissez-faire leadership style. Which of the following actions
should the nurse expect from the leader during the session?
A. The leader encourages group members to remain silent until questions are called for
B. The leader lecture about medication adverse effects to the group members
C. The leader allows the group to discuss whatever they would like to regarding their
medications
D. The leader has group members vote on what they would like to learn about during the
session
Answer: C. The leader allows the group to discuss whatever they would like to regarding their
medications
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. “You can add the medication to a half-cup of your child’s favorite juice. ”
B. “Repeat the dose if your child vomits within 1 hour after taking medication. ”X
C. “Limit your child’s potassium intake while she is taking this medication. ”
D. “Have your child drink a small glass of water after swallowing the
Answer: D. “Have your child drink a small glass of water after swallowing the
A nurse is providing teaching to a patient who has a depressive disorder and a new prescription
for phenelzine. Which of the following foods should the nurse instruct the patient to avoid?
A. Grapefruit
B. Spinach
C. Cottage cheese- cream cheese ok.
D. Smoked salmon TYRAMINE!
Answer: D. Smoked salmon TYRAMINE!
A nurse is planning care for a patient who has COPD and weighs 99 lb. The provider has
prescribed a diet of a 1. 5 g protein/kg/day. How many grams of protein per day should the
nurse include in the client’s dietary plan? (Round to the nearest whole number)
Answer: 68
A nurse is planning care for a patient who has bipolar disorder and is experiencing mania.
Which of the following interventions should the nurse include in the plan?
A. Encourage the patient to spend time in the day room
B. Withdraw the client’s TV privileges if he does not attend group therapy
C. Encourage the patient to take frequent rest periods
D. Place the patient in seclusion when he exhibits signs of anxiety
Answer: C. Encourage the patient to take frequent rest periods
A parish nurse is leading a support group for clients whose family members have committed
suicide. Which of the following strategies should the nurse plan to use during the group
session?
A. Initiate a discussion with clients about ways to cope with changes in family dynamics
B. Encourage clients to establish a timeline for their own grieving process
C. Discourage clients from sharing negative aspects of their relationship with the deceased
persons
D. Assist clients in identifying ways suicide could have been prevented
Answer: A. Initiate a discussion with clients about ways to cope with changes in family
dynamics
A nurse manager observes two staff nurses reviewing the computer records of a patient who is
not under their care. Which of the following actions should the nurse manager take first?
A. Instruct the nurses to close the client’s computer record
B. Request the nurses present an in-service on patient confidentiality
C. Advise the nurses to read the facility’s confidentiality policy
D. Place documentation of the nurses’ actions in the personnel file
Answer: A. Instruct the nurses to close the client’s computer record
A nurse is reviewing the medical record of a patient 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- also agranulocytosis same thing or soar throat. Clozapine has to
do with WBC brush
Answer: D. WBC count 2, 900/mm3- also agranulocytosis same thing or soar throat.
Clozapine has to do with WBC brush
A nurse is caring for several clients on a medical-surgical unit. For which of the following
nurses 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
A nurse is caring for a patient who is at 11 weeks of gestation. Which of the following
immunizations should the nurse ?
A. Influenza
B. Measles, mumps and rubella
C. Human papilloma virus
D. Varicella
Answer: A. Influenza
A nurse is inserting an indwelling catheter for a male client. Which of the following actions
should the nurse take?
A. Perform the cleansing procedure with a fresh swab two times
B. Lift the penis so that it is perpendicular to the client’s body
C. Cleanse the tip of the penis in a side-to-side motion
D. Pick up the catheter 13 cm (5 cm) from its tip
Answer: B. Lift the penis so that it is perpendicular to the client’s body
A nurse is providing teaching to a patient 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- low platelet
B. Faintness upon rising
C. Swelling of the face
D. Urinary frequency
Answer: C. Swelling of the face
A nurse has received change-of-shift report for a group of clients. Which of the following
actions should the nurse take to manage time effectively?
A. Document patient care at the end of the shift
B. Make the patient to-do list for the day
C. Skip breaks until the patient tasks are completed
D. Focus on several patient tasks at a time
Answer: B. Make the patient to-do list for the day
A nurse is developing a plan of care for a newborn whose mother tested positive for heroin
during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the
following actions should the nurse include in the plan?
A. Minimize noise in the newborn’s environment
B. Administer naloxone to the newborn
C. Swaddle the newborn with his legs extended
D. Maintain eye contact with the newborn during feedings
Answer: A. Minimize noise in the newborn’s environment
A nurse is assessing the fontanels of an 8-month-old infant. Which of the following findings
should the nurse recognize as an expected finding?
A. The anterior fontanel is open
B. The posterior fontanel is open
C. Both fontanels are the same size
D. Both fontanels show molding
Answer: A. The anterior fontanel is open
A nurse is caring for patient who has acute diverticulitis (low fiber) . Which of the following
diets should the nurse recommend to the client? Diverticulosis- High fiber
A. High residue
B. Lactose-free
C. Gluten-free
D. Low-fiber
Answer: D. Low-fiber
A nurse is caring for a patient who is 48 hr postoperative following a total hip arthroplasty.
Which of the following actions should the nurse include in the plan of care?
A. Administer low-dose heparin
B. Place the patient on a full liquid diet
C. Use an incentive spirometer every 3 hr
D. Maintain the patient on bed rest
Answer: A. Administer low-dose heparin
A nurse is providing teaching to the parent of an infant who has a cleft lip palate. Which of the
following feeding techniques should the nurse include in the teaching?
A. Burp the infant frequently during feedings
B. Position the nipple at the front of the infant’s mouth
C. Hold the infant in a supine position
D. Use feeding devices without nipples
Answer: A. Burp the infant frequently during feedings
A nurse in an acute mental health care facility is prioritizing care for multiple clients. Which of
the following clients should the nurse see first?
A. A patient who depressive disorder and requires assistance with ADLs
B. A patient who has obsessive-compulsive disorder and is upset about a change in a daily
routine
C. A patient who is taking clozapine to treat schizophrenia and reports sore throat
D. A patient who has narcissistic personally disorder and is mocking other during group
therapy
Answer: D. A patient who has narcissistic personally disorder and is mocking other during
group therapy
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
A nurse is performing an admission assessment for a patient who is in the manic phase of
bipolar disorder. Which of the following behaviors should the nurse expect?
A. Performance of ritualistic behaviors- ocd
B. Suspiciousness and distrust- schizo
C. Distractibility and poor judgment
D. Reports of physical discomfort -anxiety
Answer: C. Distractibility and poor judgment
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-they get upper extremity hyper, lower extremity hypo
B. Frequent nosebleeds- yes
C. Upper extremity hypotension
D. Increased intracranial pressure
Answer: A. Weak femoral pulses-they get upper extremity hyper, lower extremity hypo
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 patient might act seductively”- histrionic
B. “The patient is overly concerned about minor details”- ocd
C. “The patient exhibits impulsive behavior”
D. “The patient is exceptionally clingy to others”- dependent
Answer: C. “The patient exhibits impulsive behavior”
A nurse is assessing a patient who has a chest tube with a water seal drainage system. Upon
assessment, the nurse notes tidaling in the water seal. Which of the following is an explanation
for the tidaling? Tidling in water seal and continuous in suction chamber okay! Water seal
bubbling is air leak.
A. There is a loop of tubing below the drainage system
B. The system is working properly
C. The lung has re-expanded
D. The tubing is partially obstructed by clots
Answer: C. “The patient exhibits impulsive behavior”
A nurse in an emergency department is caring for a patient who is experiencing stimulant
withdrawal. Which of the following findings should the nurse expect?
A. Runny nose
B. Decreased appetite -Increased appetite
C. Muscle spasms
D. Fatigue, depression, agitated, anxiety, craving, increased appetite
Answer: D. Fatigue, depression, agitated, anxiety, craving, increased appetite
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. A history of being in prison
B. Experiencing delusions
C. Male gender
D. Previous violent behavior
Answer: D. Previous violent behavior
A nurse is preparing to feed a newly admitted patient who has dysphagia. Which of the
following actions should the nurse plan to take?
A. Instruct the patient to lift her chin when swallowing X
B. Talk to the patient during feeding X
C. Discourage the patient from coughing during feedings
D. Sit at or below the client’s eye level during feedings
Answer: D. Sit at or below the client’s eye level during feedings
A nurse is providing teaching to a patient who has a depressive disorder and a new prescription
for amitriptyline. Which of the following statements by the patient indicates an understanding
of the teaching?
A. “I expect this medication to raise my blood pressure”
B. “I should take this medication on an empty stomach”
C. “I can continue to take St. John’s wort while taking this medication”
D. “I know it will be a couple of weeks before the medication helps me feel better”
Answer: D. “I know it will be a couple of weeks before the medication helps me feel better”
A nurse is developing a nutritional care plan for a patient who has COPD and severe dyspnea.
To promote intake, which of the following actions should the nurse include in the plan of care?
A. Ambulate the patient before each meal
B. Offer the patient three large meals each day X
C. Administer a bronchodilator after meals
D. Limit fluid intake with meals YES drinking before and after can bloat you
Answer: D. Limit fluid intake with meals YES drinking before and after can bloat you
A nurse in the emergency department is assessing a patient who has major depressive disorder.
Which of the following actions should the nurse take first? (Exhibit)
A. Encourage the patient to verbalize feelings
B. Assess for hopelessness Implement seizure precautions for the client
C. Administer ondansetron to the patient for nausea
D. Obtain the client’s weight
Answer: A. Encourage the patient to verbalize feelings
A home health nurse is completing screenings for elder abuse during patient visits. Which of
the following findings should the nurse identify as an indication of potential elder abuse?
A. A patient who lives with family members and begins to take more responsibility of self-care
B. A patient who reports being given sedative medications by family members
C. A patient who is taking warfarin and has several small bruises on her shins and hands
D. A patient who schedules multiple visits with his provider every month
Answer: B. A patient who reports being given sedative medications by family members
A nurse is planning care for a patient who is to receive alteplase recombinant for a thrombus in
the coronary artery. Which of the following actions should the nurse include in the plan of
care? Alteplase treats strokes, heart attacks and clots.
A. Administer medications intramuscularly X- it is IV
B. Provide a diet low in protein X- why
C. Observe for bruising of the skin- check for bleeding
D. Monitor vital signs every hour for the first 4 hr- X every 15 min for the first hour
Answer: C. Observe for bruising of the skin- check for bleeding
A nurse is caring for a patient who is postoperative following an appendectomy and is
receiving gentamicin. Which of the following assessment findings should the nurse identify as
an adverse effect of this medication?
A. Creatinine 2. 3 mg/dL (0. 6-1. 2) nephrotoxicity
B. Respiratory rate 22/min
C. 2+ pitting edema of the ankles
D. Hgb 8. 7 g/dL
Answer: A. Creatinine 2. 3 mg/dL (0. 6-1. 2) nephrotoxicity
A nurse in an acute care facility is caring for a patient who is homeless and has a decubitus
ulcer. Which of the following actions should the nurse take as a
Client advocate?
A. Gather dressing supplies for the client’s discharge
B. Provide patient teaching about nutrition
C. Consult with the facility’s quality improvement team
D. Contact the facility’s case management department
Answer: D. Contact the facility’s case management department
A nurse is caring for patient who has diarrhea and is receiving intermittent enteral feedings.
Which of the following actions should the nurse take?
A. Discard the open can of formula after 36 hr
B. Administer feedings at a slower rate can give d10W.
C. Flush the tube with 10 mL of water after feedings
D. Provide chilled formula- room temperature
Answer: B. Administer feedings at a slower rate can give d10W.
A nurse is caring for a patient who is postoperative and has a new prescription for
hydromorphone. Which of the following actions should the nurse take?
A. Withhold the medication if the patient does not appear to be in pain
B. Withhold the medication if the patient has a fever
C. Document administration of the medication upon removal from theme dictation dispensing
system
D. Count the current number of unit doses available in the Medication dispensing system
Answer: D. Count the current number of unit doses available in the Medication dispensing
system
A nurse in a provider’s office is caring for a patient who asks about using acupuncture to
manage his osteoarthritis pain. The nurse should identify which of the following conditions as
a contraindication for receiving this treatment?
A. Herpes zoster
B. Hypertension
C. Obesity
D. Hypothyroidism
Answer: A. Herpes zoster
A nurse is assessing a patient following abdominal surgery. Which of the following findings
should the nurse report to the provider?
A. Temperature 37. 6 C (99. 7 F)
B. Urinary output 20 mL/hr
C. Blood pressure 100/70 mm Hg
D. Serious drainage on abdominal dressing
Answer: B. Urinary output 20 mL/hr
A nurse in a long-term care facility is admitting a patient who has dementia. Which of the
following actions should the nurse take to reduce the risk for patient injury?
A. Place the bedside table at the foot of the bed
B. Keep the television on during the night
C. Assist the patient to the toilet frequently
D. Raise the side rails up when the patient is in bed
Answer: C. Assist the patient to the toilet frequently
A certified IV nurse is providing education about peripherally inserted central catheters (PICC)
to a newly licensed nurse. Which of the following statements by the newly licensed nurse
indicates an understanding of the teaching?
A. “Use a vein in the middle of the lower arm to insert a PICC”- above elbow, below shoulder
B. “Flush a PICC using a 3-mililiter syringe”- 10 mL
C. “Informed consent is required prior to a PICC placement”
D. “Position the client’s arm in adduction for PICC placement”
Answer: C. “Informed consent is required prior to a PICC placement”
A nurse is teaching self-administration of insulin glargine to a patient who has type 1diabetes
mellitus. Which of the following statements by the patient indicates an understanding of the
teaching?
A. “I will take this insulin before meals”
B. “I will not mix this insulin with other types of insulin”
C. “I will rotate the injection sites between my arm and my thigh” (abdomen)
D. “I will shake the vial to mix the insulin” (you must roll)
Answer: B. “I will not mix this insulin with other types of insulin”
When assessing a patient for pneumonia in the lower lobe base, where should the nurse
auscultate?
A. Anterior chest, midline
B. Lateral chest, upper quadrant
C. Posterior chest, lower lobes
D. Anterior chest, upper lobes
Answer: C. Posterior chest, lower lobes
A nurse is caring for a patient who is immunocompromised. Which of the following antiseptic
solutions should the nurse use to perform hand hygiene?
A. Isopropyl alcohol
B. Bleach
C. Chlorhexidine
D. Povidone-iodine
Answer: C. Chlorhexidine
A nurse is assessing a patient in the emergency department. Which of the following actions
should the nurse take first? (exhibit)
A. Place the patient on a cooling blanket
B. Obtain arterial blood gas levels
C. Elevate the head of the client’s bed to 30
D. Administer an analgesic
Answer: C. Elevate the head of the client’s bed to 30
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”
A nurse is teaching a prenatal class about infection prevention at a community center.
Which of the following statements by a patient 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”
A nurse is caring for a patient 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 contra indication to the
procedure?
A. Primary glaucoma
B. Amputation
C. Hypertension
D. Osteoarthritis
Answer: C. Hypertension
A home health nurse is planning care for a patient who has Alzheimer’s disease. Which of the
following actions should the nurse include in the plan of care?
A. Replace the carpet with hardwood floors
B. Place locks at the tops of exterior doors
C. Wear clothing with zippers instead of buttons
D. Encourage physical activity prior to bedtime
Answer: B. Place locks at the tops of exterior doors
A nurse is caring for a patient who repeatedly refuses meals. The nurse overhears an assistive
personal (AP) telling the client, “If you don’t eat, I’ll put restraints on your wrists and feed
you. ” The nurse should intervene and explain to the AP that this statement constitutes which of
the following torts?
A. Malpractice
B. Negligence
C. Assault
D. Battery
Answer: C. Assault
A nurse is reviewing a client’s laboratory results prior to surgery. Which of the following
findings should the nurse report to the provider?
A. Bicarbonate 26 mEq/L (normal range: 22-28 mEq/L)
B. Chloride 100 mEq/L (normal range: 96-106 mEq/L)
C. Potassium 3.8 mEq/L (normal range: 3.5-5.0 mEq/L)
D. Sodium 160 mEq/L (normal range: 135-145 mEq/L)
Answer: D. Sodium 160 mEq/L (normal range: 135-145 mEq/L)
A charge nurse is evaluating a newly licensed nurse’s understanding of advance directives.
Which of the following statements by the newly licensed nurse indicates an understanding of
advance directives?
A. “I’ll refer clients who do not have advance directives for legal assistance”
B. “I have to witness a client’s signature on his advance directives”
C. “I have to document whether or not a patient has prepared his advance directives”
D. “I’ll encourage clients to follow their provider’s wishes for end-of-life care”
Answer: C. “I have to document whether or not a patient has prepared his advance directives”
A clinic nurse is assessing an 8-year-old child during an annual physical examination. Which
of the following findings indicates the need for intervention by the nurse?
A. The patient eats at least one snack daily
B. The client’s height has increased by 6. 35 cm (2. 5 in) 2 inches/year
C. The client’s weight has increased by 0. 9 kg (2 lb)- should gain at least 4-6 lbs
D. The patient drinks 3 cups of 1% milk per day
Answer: C. The client’s weight has increased by 0. 9 kg (2 lb)- should gain at least 4-6 lbs
A nurse is assessing a patient who presents to the labor and delivery unit reporting the onset of
contractions. Which of the following findings should the nurse identify as a manifestation of
false labor?
A. Presence of a bloody show
B. Intermittent, painless contractions
C. Slow change in dilation and effacement
D. Contraction intensity increased by ambulation
Answer: B. Intermittent, painless contractions
A nurse is caring for a patient who has a urinary tract infection and has been taking cefaclor.
Which of the following serum laboratory results indicates the medication is effective?
A. Creatinine 2. 3 mg/dL
B. BUN 32 mg/dL
C. Eosinophils 3. 9%
D. WBC 9, 200 mm3
Answer: D. WBC 9, 200 mm3
A charge nurse is mentoring a newly licensed nurse. Which of the following actions by the
newly licensed nurse indicates the need for intervention by the charge nurse?
A. Uses an IV infusion pump to administer total parenteral nutrition to a client
B. Inserts an NG tube for a patient using clean technique
C. Crushes an Sub Lingual tablet to administer into a client’s feeding tube
D. Stabilizes a client’s indwelling urinary catheter with the nondominated hand prior to
inflation of the balloon
Answer: C. Crushes an Sub Lingual tablet to administer into a client’s feeding tube
A nurse is reviewing laboratory results for a patient who has a heart failure and notes a serum
potassium level of 5. 2 mEq/L. Which of the following medications should the nurse withhold?
A. Furosemide
B. Spironolactone
C. Atorvastatin
D. Metoprolol
Answer: B. Spironolactone
A nurse is teaching a patient who has migraine headaches how to use biofeedback to reduce the
need for pharmacological interventions. Which of the following information should the nurse
include in the teaching?
A. “Biofeedback stimulates certain pressure points to relax muscles”
B. “Biofeedback improves energy flow through soft tissue manipulation to increase
circulation”
C. “Biofeedback requires concentration to control physiological responses”
D. “Biofeedback uses herbs to reduce inflammation”
Answer: C. “Biofeedback requires concentration to control physiological responses”
A nurse is teaching the parents of a child who has a new onset of seizures and is to undergo an
electroencephalogram (EEG) about the procedure. Which of the following instructions should
the nurse include in teaching?
A. “Give the child acetaminophen for pain following the procedure”
B. “Ensure the child’s hair is clean and without conditioner before the procedure”
C. “Keep the child out of the sun for 4 hr following the procedure”
D. “Make the child NPO before the procedure”
Answer: B. “Ensure the child’s hair is clean and without conditioner before the procedure”
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”
A nurse in an outpatient mental health facility is providing teaching to a group of adolescents.
Which of the following statements by a patient indicates an understanding of the teaching?
A. “I will limit my alcohol use to one drink daily while taking disulfiram” X not within 12
hours
B. “I will take my lithium on an empty stomach” X with food
C. “I will take the sustained-release methylphenidate every morning”
D. “I will avoid foods containing tyramine while taking fluoxetine” ssri X
Answer: C. “I will take the sustained-release methylphenidate every morning”
A nurse is caring for a patient who is 4 days postpartum. Which of the following assessment
findings should the nurse expect? (Select all that apply)
A. Foul perineal odor
B. Lochia serosa
C. Postpartum
D. Fundus displaced to the right
E. Fundus 4 cm (1. 6 cm) below the umbilicus decends 1cm per day
Answer: B. Lochia serosa
E. Fundus 4 cm (1. 6 cm) below the umbilicus decends 1cm per day
A nurse is providing discharge teaching to a patient following a total gastrectomy. The nurse
should instruct the patient about which of the following medications
A. Vitamin K
B. Ranitidine
C. Metoclopramide
D. Vitamin B12- lifelong
Answer: D. Vitamin B12- lifelong
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- cup shape
B. Perform the procedure twice a day
C. Administer a bronchodilator after the procedure
D. Perform the procedure prior to meals
Answer: B. Perform the procedure twice a day
A nurse at a community health clinic is planning care for an adolescent who recently learned
that she is pregnant and is concerned about her ability to afford and care for her baby. Which of
the following actions should the nurse take?
A. Contact the adolescent’s parent for assistance
B. Advise the adolescent to place the newborn for adoption
C. Assist the adolescent in applying for Medicaid
D. Refer the adolescent to a local mental health clinic
Answer: C. Assist the adolescent in applying for Medicaid
A nurse is admitting an older adult patient who is transferring from another facility. The nurse
notes pressure ulcers on the client’s coccyx and abrasions around both wrists. Which of the
following actions should the nurse take to address suspicions of elder abuse?
A. Contact the family regarding the client’s condition
B. Notify risk management
C. Privately interview the patient about her condition
D. Inform the transferring agency of the client’s condition
Answer: C. Privately interview the patient about her condition
A nurse is caring for a patient who is experiencing expressive aphasia and right hemiparesis
following a cerebrovascular accident. Which of the following actions by the nurse best
promotes communications among staff caring for the client?
A. Noting changes in the treatment plan in the client’s medical record
B. Recording the client’s progress in the nurses’ notes
C. Posting swallowing precautions at the head of the client’s bed
D. Having interdisciplinary team meetings for the patient on a regular basis
Answer: D. Having interdisciplinary team meetings for the patient on a regular basis
A nurse is caring for a patient who has an indwelling urinary catheter. Which of the following
actions should the nurse take to provide catheter care?
A. Empty the collected urine once every 24 hr
B. Hang the drainage bag on a bed rail
C. Provide perineal hygiene after defecation
D. Change the indwelling catheter every 8 hr
Answer: C. Provide perineal hygiene after defecation
A nurse is assisting a patient who has acute glomerulonephritis to choose menu items for
breakfast. Which of the following food choices should the nurse recommend?
A. Eggs
B. Banana X
C. Smoked salmon X
D. Bagel
Answer: D. Bagel
A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her
position at the clinic. Which of the following tasks should the nurse identify as tertiary
prevention?
A. Helping clients understand health screenings covered by their insurance plans
B. Using an electronic messaging system to remind clients when to take medications
C. Educating clients about contraindications to specific immunizations
D. Providing clients with information about the benefits of exercise
Answer: B. Using an electronic messaging system to remind clients when to take medications
A nurse in a long-term care facility is managing the care of an older adult patient who has
difficulty swallowing and occasional choking during meals. The nurse should initiating a
referral to which of the following members of the interprofessional care team?
A. Occupational therapist
B. Respiratory therapist
C. Social worker
D. Speech-language pathologist
Answer: D. Speech-language pathologist
A nurse is performing a preoperative assessment for a patient who reports having an allergy to
several goods. Which of the following food allergies indicates a risk factor for a latex allergy?
A. Peanuts
B. Eggs
C. Bananas
D. Shrimp
Answer: C. Bananas
A nurse is planning care for a patient who is scheduled to receive a peripherally inserted central
catheter in the arm. Which of the following interventions is appropriate for the nurse to include
in the plan care?
A. Measure the arm circumference above the insertion site daily
B. Schedule an MRI post procedure to verify placement (Xray) X
C. Administer sedation for the procedure X local anesthetic
D. Use gauze to secure an arm board to involved extremity- used for midline
Answer: A. Measure the arm circumference above the insertion site daily
A nurse is caring for a group of clients. Which of the following wounds should the nurse
expect to heal by primary intention? Primary fastest type on its own, secondary requires
granulation tissues and creates scar tissues, and tetriary is delayed wound closure.
A. Approximated surgical incision
B. Infected laceration- Tertiary
C. Stage II pressure ulcer -Secondary
D. Partial-thickness burn- Secondary
Answer: A. Approximated surgical incision
A nurse is performing a change-of-shift assessment. Which of the following clients has the
priority finding?
A. A patient who has a first-degree heart block and a heart rate of 62/min
B. A patient who is 2 hr post cast placement and has a 2+ pitting edema and pallor
C. A patient who has pneumonia with a productive cough and a fever of 38. 8 C(101.8 F)
D. A patient who has type 2 diabetes mellitus and a blood glucose of 250 mg/dL
Answer: B. A patient who is 2 hr post cast placement and has a 2+ pitting edema and pallor
A nurse on a medical-surgical unit delegating tasks to an assistive personnel (AP). Which of
the following patient care tasks is within the scope of practice for the AP?
A. Interpreting blood glucose values
B. Performing postmortem care
C. Explaining the steps for a 24-hr urine collection
D. Assisting with low-carbohydrate diet selections
Answer: B. Performing postmortem care
A nurse in a mental health clinic receives a request from a patient 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 aren’t 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 aren’t included”
A nurse is providing teaching to a patient who has thrombocytopenia following chemotherapy.
Which of the following statements indicates an understanding of the teaching?
A. “I will wipe my nose instead of blowing it”
B. “I will remove my shoes when I’m inside my house”
C. “I will floss between my teeth every time I brush”
D. “I will use an enema to manage my constipation”
Answer: A. “I will wipe my nose instead of blowing it”
A home care nurse is making follow-up visit with a patient has COPD and is using a
compressed oxygen system in his home. Which of the following actions should the nurse take?
A. Store the oxygen tank wrench in a locked cabinet
B. Have the patient store smaller tanks under his bed
C. Ensure that the patient checks the gauge weekly
D. Place the oxygen tank away from curtains or drapes
Answer: D. Place the oxygen tank away from curtains or drapes
A nurse is conducting health promotion education regarding contraindications to combination
oral contraceptive use to a group of women. Which of the following conditions should the
nurse include in the teaching?
A. Renal calculi
B. Fibrocystic breast disease
C. Fibromyalgia
D. Hypertension
Answer: D. Hypertension
A nurse is caring for a patient following a thyroidectomy. For which of the following
complications should the nurse assess the client?
A. Hypokalemia
B. Muscular depression
C. Laryngeal stridor
D. Hyperglycemia
Answer: C. Laryngeal stridor
A nurse is teaching a patient who is to start a new prescription for Which of the following
instructions should the nurse include?
A. “Take with the protein snack” – limit protein
B. “Report dark-colored urine”- this normal
C. “Monitor for hyperglycemia”
D. “Change positions slowly”
Answer: D. “Change positions slowly”
A nurse is caring for a school-age child who is postoperative and received morphinevia IV
bolus for pain 10 min ago. Which of the following findings is the nurse’s priority?
A. Constipation
B. Sedation
C. Euphoria
D. Bradypnea
Answer: D. Bradypnea
A nurse is teaching the parents of a 6-year-old child who has sickle cell anemia about
managing the disease. The nurse should emphasize the importance of which of the following
factors to prevent a sickle cell crisis?
A. Adequate hydration
B. Calorie restriction
C. Increased iron intake
D. A low-protein diet
Answer: A. Adequate hydration
A community health nurse is working with a group of clients. The nurse practices the ethical
principle of distributive justice by performing which of the following tasks?
A. Accepting the decision of an older adult patient to live alone in her home
B. Ensuring that a patient who is homeless receives preventive medical care- be fair
C. Keeping a promise to visit with a patient who is housebound after the delivery of care
D. Being honest with the parents of a child about the need to report suspected abuse
Answer: B. Ensuring that a patient who is homeless receives preventive medical care- be fair
A home health nurse is assessing a patient who has amyotrophic lateral sclerosis(ALS) and has
had recent weight loss. Which of the following is the priority admission data for the nurse to
obtain?
A. Changes in appetite
B. Prescribed medications
C. Swallowing ability
D. Daily fluid intake
Answer: C. Swallowing ability
A nurse is caring for a patient who has a new prescription for piperacillin/tazobactum 3. 75 g
intermittent IV bolus Q6H to infuse over 30 min. Available is piperacillin/tazobactum 3. 75 g
in 50 mL 0. 9% sodium chloride. The nurse should the infusion pump to deliver how many
mL/hr?
A. 100 mL/hr
B. 75 mL/hr
C. 50 mL/hr
D. 125 mL/hr
Answer: A. 100 mL/hr
A nurse is assessing a patient who has acute angle-closure glaucoma. Which of the following
findings should the nurse expect?
A. Increased light perception
B. Reddened cornea
C. Severe periocular pain
D. Gray cast sclera
Answer: C. Severe periocular pain
A nurse is caring for a patient who has pneumonia and has gained 4. 2 kg (9. 3 lb) over the last
5 days. The client’s laboratory values this morning are the following: WBC 10, 000/mm3, RBC
5. 2 million/mm3, platelets 250, 000mm3, BUN 32 mg/dL, and serum creatinine 2. 1 mg/dL.
The nurse should report these findings to which of the following members of the
interdisciplinary team?
A. Dietitian
B. Infection control nurse
C. Nephrologist
D. Cardiologist
Answer: C. Nephrologist
A nurse is caring for a toddler who has retinoblastoma (cancer of eye). Which of the following
findings should the nurse expect?
A. Hyphema
B. Opacity of the lens
C. Nystagmus
D. White eye reflex
Answer: D. White eye reflex
A nurse is providing discharge teaching about home care of a surgical incision to a patient who
does not speak the same language as the nurse. The nurse is communicating with the patient
using an interpreter. Which of the following actions should the nurse take?
A. Use gestures to convey meaning
B. Speak directly to the client
C. Pause in the middle of sentences
D. Speak slowly when talking to the interpreter
Answer: B. Speak directly to the client
A nurse is providing teaching about exercise to a patient who is at 28 weeks of gestation.
Which of the following statements by the patient indicates an understanding of the teaching?
A. “I can continue to do exercises that require the supine position” X
B. “I should check my pulse rate once every hour while exercising”
C. “I should increase my exercise level to prepare for labor” X
D. “I should drink 16 to 24 ounces of water after I exercise”
Answer: D. “I should drink 16 to 24 ounces of water after I exercise”
A nurse is providing discharge teaching to the parents of toddler who hascystic fibrosis.
Which of the following instructions should the nurse include?
A. “Use a nebulizer to administer a bronchodilator following airway clearance therapy”
B. “Restrict intake of foods that contain gluten”
C. “Perform chest percussion and postural drainage at least twice daily”
D. “Administer pancreatic enzymes on an empty stomach”- X with meal
Answer: C. “Perform chest percussion and postural drainage at least twice daily”
A nurse is developing a plan of care for a patient who has preeclampsia (high bp) 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 patient 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
A nurse is planning discharge teaching for a patient who is to start a new prescription for
metoprolol. For which of the following should the nurse instruct the patient to monitor and
report to the provider?
A. Tinnitus
B. Polyuria
C. Hyperglycemia
D. Bradycardia
Answer: D. Bradycardia
A nurse is providing teaching to the parents of a newborn who has been circumcised. Which of
the following instructions should the nurse include in the teaching?
A. “Remove yellow exudate around the penis”
B. “Wrap sterile gauze around the penis if bleeding occurs”
C. “Use soap to cleanse the site”
D. “Apply petroleum jelly to the glans with diaper changes”
Answer: D. “Apply petroleum jelly to the glans with diaper changes”
A nurse is developing a care plan for a patient who is in Buck’s traction and is scheduled for
surgery for a fractured femur of the right leg. Which of the following interventions should the
nurse delegate to an assistive personnel?
A. Remind the patient to use the incentive spirometer
B. Ask the patient to describe her pain
C. Observe the position of the suspended weight
D. Check the client’s pedal pulse on the right leg
Answer: A. Remind the patient to use the incentive spirometer
A nurse is assessing the growth and development of a 3-year-old child. Which of the following
questions should the nurse ask the parent to determine if the child exhibiting typical
developmental expectations?
A. “Can your child catch and throw a small ball?”
B. “Can your child ride a tricycle?”
C. “Can your child name give colors?”
D. “Can your child draw a stick figure?”
Answer: B. “Can your child ride a tricycle?”
A nurse is caring for a newborn whose mother was taking methadone during her pregnancy.
Which of the following findings indicates the newborn is experiencing withdrawal?
A. Bradycardia
B. Acrocyanosis
C. Hypertonicity
D. Bulging fontanels
Answer: C. Hypertonicity
A charge nurse is admitting four clients to an acute care unit. Which of the following clients
should the nurse place near the nurses’ station?
A. A patient who is on fluid restriction
B. A patient who is in Buck’s traction
C. A patient who has orthostatic hypotension
D. A patient who has an open wound
Answer: C. A patient who has orthostatic hypotension
A nurse is caring for a patient who has pneumonia and tells the nurse, “I feel like an elephant is
sitting on my chest. ” The patient is weak and unable to walk. After the nurse initiates chest
pain protocol, which of the following is the priority diagnostic test?
A. Serum potassium
B. 12-lead ECG
C. PT and INR
D. Chest x-ray
Answer: B. 12-lead ECG
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 patient admissions,
which of the following current clients should the nurse recommend for early discharge?
A. A patient who has COPD and a respiratory rate of 44/min
B. A patient who has cancer with a sealed implant for radiation therapy
C. A patient who is receiving heparin for deep-vein thrombosis
D. A patient who is 1 day postoperative following a vertebroplasty
Answer: D. A patient who is 1 day postoperative following a vertebroplasty
A home health nurse is caring for a child who has Lyme disease. Which of the following is an
appropriate action for the nurse to take?
A. Assess for skin necrosis
B. Educate the family to avoid sharing personal belongings
C. Ensure the state health department has been notified
D. Administer antitoxin
Answer: C. Ensure the state health department has been notified
A nurse is reviewing annual educational requirements for fire safety. Identify the sequence the
nurse should use when operating a fire extinguisher. (move the steps of using a fire
extinguisher in order)
A. Point the hose at the base of the fire
B. Sweep the extinguisher from side to side
C. Squeeze the handles together
D. Unlock the handle by pulling on the pin
Answer: D. Unlock the handle by pulling on the pin
C. Squeeze the handles together
A. Point the hose at the base of the fire
B. Sweep the extinguisher from side to side
Which of the following describes the correct steps to operate a fire extinguisher using the
PASS acronym?
A. Pull, Aim, Squeeze, Sweet
B. Pull, Point, Squeeze, Sweep
C. Push, Aim, Squeeze, Sweep
D. Pull, Aim, Squeeze, Spray
Answer: B. Pull, Point, Squeeze, Sweep
The PASS acronym stands for:
A. Pull the pin
B. Aim the nozzle
C. Squeeze the handle
D. Sweep the extinguisher from side to side
E. All of these
Answer: E. All of these
A nurse is caring for a patient who has a nasogastric tube. Which of the following actions
should the nurse take to verify tube placement prior to each feeding?
A. Auscultate air insertion into the tube
B. Test the bilirubin level of gastric contents
C. Palpate the abdomen for tube placement
D. Test the pH of gastric contents
Answer: D. Test the pH of gastric contents
A nurse is preparing to assess fetal heart tones for a patient who is at 12weeks of gestation.
Which of the following actions should the nurse take?
A. Perform Leopold maneuvers prior to auscultating the fetal heart rate
B. Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate
C. Measure the fundal height to determine the placement of the ultra sound stethoscope
D. Place the patient in a side-lying position prior to assessing the fetal heart rate
Answer: B. Position the ultrasound stethoscope above the symphysis pubis to assess the fetal
heart rate
While performing a routine assessment, a nurse notices fraying on the electrical cord of a
client’s continuous passive motion (CPM) device. Which of the following actions should the
nurse take first?
A. Ensure the device inspection sticker is current
B. Report the defect to the equipment maintenance staff
C. Remove the device from the room cc
D. Initiate a requisition for replacement CPM device
Answer: C. Remove the device from the room cc
A nurse is caring for a newly admitted patient who has bacterial meningitis. Which of the
following actions should the nurse take?
A. Implement seizure precautions
B. Monitor the patient for hypoglycemia
C. Perform range-of-motion exercises once per shift
D. Place the patient in high-Fowler’s position
Answer: A. Implement seizure precautions
A nurse is providing teaching to a patient about the adverse effects sertraline. Which of the
following adverse effects should the nurse include?
A. Excessive sweating Yes diaphoresis
B. Increased urinary frequency
C. Dry cough
D. Metallic taste in mouth
Answer: A. Excessive sweating Yes diaphoresis
A nurse is assessing a patient who is in active labor. Which of the following findings should the
nurse report to the provider?
A. Contractions lasting 80 seconds- too long?
B. FHR baseline 170/min normal 110-160
C. Early decelerations in the FHR
D. Temperature 37. 4 C (99. 3 F)
Answer: B. FHR baseline 170/min normal 110-160
A nurse is preparing a patient to undergo a cardiac catheterization. Which of the following
tasks should the nurse perform prior to the procedure?
A. Draw blood specimens for culture and sensitivity
B. Administer nitroglycerin 0. 4 mg SL 30 min before the procedure
C. Transport the patient to radiology for a CT scan
D. Obtain a CBC with differential
Answer: D. Obtain a CBC with differential
A nurse is developing a plan of care for a patient who has schizophrenia and is experiencing
auditory hallucinations. Which of the followings actions should the nurse include in the plan?
A. Ask the patient directly what he is hearing
B. Encourage the patient 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 patient directly what he is hearing
A nurse is reviewing the preadmission laboratory test results of a patient who is to undergo hip
arthroplasty in 2 days. Which of the following results should the nurse report to the provider?
A. Sodium 142 mEq/L (normal)
B. Potassium 3. 3 mEq/L (Low)
C. Blood glucose 80 mg/dL (normal)
D. PT 11. 5 seconds (11-13. 5)
Answer: B. Potassium 3. 3 mEq/L (Low)
A nurse is in the emergency department is caring for a patient who has a new diagnosis of
acute myocardial infarction and is being treated with a thrombolytic, aspirin, and IV heparin.
Which of the following findings should indicate to the nurse that the patient is experiencing a
satisfactory response to these interventions?
A. The client’s stool is guaiac positive
B. S3 heart sounds are present
C. The client’s a PTT is two times the control
D. Q wave is noted on the cardiac monitor tracing
Answer: C. The client’s a PTT is two times the control
A nurse observes a patient on the psychiatric unit muttering and standing near a window. The
patient states, “The voices are telling me to jump. ” Which of the following is an appropriate
response by the nurse?
A. “I understand the voices are frightening you, but I do not hear any voices”
B. “Do you recognize the voices as belonging to anyone you know?”
C. “You shouldn’t be afraid when you think the voices are telling you to hurty ourself”
D. “That can’t be true. The only voices in this room are yours and mine”
Answer: A. “I understand the voices are frightening you, but I do not hear any voices”
A home health nurse is visiting a patient whose partner states that she is overwhelmed by
caring for him. When suggesting respite care, which of the following explanations should the
nurse provide?
A. “Respite care includes volunteers who will perform household tasks”
B. “Respite care provides clinicians to work with you in caring for your husband”
C. “Respite care offers financial resources to help care for your husband”
D. “Respite care allows for time away from caring for your husband”
Answer: D. “Respite care allows for time away from caring for your husband”
A nurse working in the postpartum unit is reviewing a client’s new prescriptions for
methylergonovine. The nurse should recognize that which of the world following is a
contraindication for this medication? Treats severe bleeding after birth
A. Hypertension
B. Confusion
C. Chlamydia
D. Polyuria
Answer: A. Hypertension
A nurse is caring for a patient 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 X-more hypotension
B. Have protamine sulfate available at the bedside- X Heparin
C. Reposition the patient side-to-side each hour
D. Monitor the patient hypertension X hypotension
Answer: C. Reposition the patient side-to-side each hour
A charge nurse observes a coworker who has impaired coordination and is drowsy while
performing routine tasks. Which of the following actions should the charge nurse take first?
A. Document observations about the nurse’s behavior
B. Report the nurse’s behavior to the nurse manager
C. Reassign the nurse’s client-care duties to another nurse CC
D. Obtain support from another nurse before filing report
Answer: C. Reassign the nurse’s client-care duties to another nurse CC
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 patient who has sinus arrhythmia and is receiving cardiac monitoring
B. A patient who has epidural analgesia and weakness in the lower extremities
C. A patient who has a hip fracture and a new onset of tachypnea
D. A patient who has diabetes mellitus and hemoglobin A1C of 6. 8%
Answer: C. A patient who has a hip fracture and a new onset of tachypnea
A nurse is caring for a patient who has implanted venous access port. Which of the following
should the nurse use to access the port?
A. A non-coring needle- Huber point needle
B. A butterfly needle
C. An angiocatheter
D. A 25-gauge needle
Answer: A. A non-coring needle- Huber point needle
A nurse is receiving change-of-shift report for four clients. Which of the following clients
should the nurse assess first?
A. A patient who has leukemia and a platelet level of 95, 000/mm3 (150-400)
B. A patient who has hepatitis B and total bilirubin of 1. 2 mg/dL (0. 1-1. 0)
C. A patient who has diabetes mellitus and a HbA1c of 5. 2%
D. A patient who received IV furosemide and has a serum potassium of 3. 6 mEq/L
Answer: A. A patient who has leukemia and a platelet level of 95, 000/mm3 (150-400)
A nurse is admitting a patient who has a history of atrial fibrillation. The nurse should
recognize that atrial fibrillation places the patient at risk for which of the following conditions?
A. Cardiac tamponade
B. Pulmonary emboli
C. Hemothorax
D. Widened pulse pressure
Answer: B. Pulmonary emboli
A nurse is teaching about home care to the parents of an infant who has a tracheostomy. Which
of the following instructions should the nurse include in the teaching?
A. “Set the suction machine to 60 mm Hg” (no higher than 95 for infants)
B. “Advance the suction catheter just past the point of resistance”
C. “Instill 2 mL of saline in the tracheostomy prior to suctioning”
D. “Apply suction for 30 seconds after advancing the catheter” (each suction attempt should be
5 seconds)
Answer: A. “Set the suction machine to 60 mm Hg” (no higher than 95 for infants)
A nurse is caring for a patient who has given informed consent for electroconvulsive therapy.
Just before the procedure, the patient tells the nurse she is considering not going forward with
the treatment. Which of the following statements by the nurse is appropriate?
A. “You don’t have to go through with the treatment”
B. “It’s okay to be nervous before this treatment”
C. “Most people who have this procedure feel better following the treatment”
D. “Your doctor wouldn’t have ordered this treatment unless it was necessary”
Answer: A. “You don’t have to go through with the treatment”
A home health nurse is providing teaching about home safety to an older adult client. Which of
the following statements by the patient indicates that the teaching has been effective?
A. “I put on socks when getting out of bed at night” (non- slip?)
B. “I have marked the steps with black tape” (brighter color?)
C. “I have grab bars next to my tub”
D. “I have placed throw rugs in the hallways” X fall risk
Answer: C. “I have grab bars next to my tub”
A nurse is providing teaching to a patient who is undergoing radiation the rapy and has
stomatitis. Which of the following responses by the patient indicates an understanding of the
teaching?
A. “I should gargle with an alcohol-based mouthwash to kill germs” plain water
B. “I should use a soft-bristle toothbrush to clean my teeth after meals” yes
C. “I should limit my intake of dairy products to prevent nausea”
D. “I should moisten my lips with lemon-glycerin swabs” lemon will irritate
Answer: B. “I should use a soft-bristle toothbrush to clean my teeth after meals” yes
A nurse is preparing to administer the first dose of cefazolin via intermittent IV infusion to a
client. Which of the following actions should the nurse take first?
A. Check the compatibility of cefazolin with the client’s existing IV fluids
B. Obtain the reconstituted antibiotic from pharmacy
C. Review the client’s allergy history
D. Assess the IV for patency
Answer: C. Review the client’s allergy history
A nurse is caring for a child who reports migraine headaches for the past 4months. Which of
the following actions should the nurse take first?
A. Review the child’s electronic pain diary
B. Set up an appointment with the school nurse
C. Refer the family to a chronic pain support group
D. Request a change in medication from the provider
Answer: A. Review the child’s electronic pain diary
A nurse is providing teaching to a patient who is receiving misoprostol for induction of labor.
Which of the following information should the nurse include in the teaching? Nothing in the
book or online, for abortion you insert, for induction you take orally
A. “You will have intermittent fetal monitoring while you receive the medication”
(intermittent)
B. “You will lie on your side for 30 minutes after the medication is inserted”(yes lie down for
30 minutes but only when aborting)
C. “You will have a urinary catheter inserted prior to the placement of the medication” ( you
should empty your bladder prior to insertion)- placement is for abortion, you get a cath when
you are under epidural
D. “You will have oxytocin initiated within 3 hours of administration of the medication”
Answer: A. “You will have intermittent fetal monitoring while you receive the medication”
(intermittent)
A nurse is assessing the peripheral catheter insertion site of a patient who is receiving an
infusion. The nurse notices redness and warmth to touch around the insertion site. The nurse
should document the finding as which of the following complications?
A. Phlebitis
B. Extravasation
C. Circulatory overload
D. Infiltration
Answer: A. Phlebitis
A nurse is caring for a patient who is in active labor and notes the FHR base line 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- tachycardia
B. Fetal anemia
C. Maternal hypoglycemia
D. Chorioamnionitis- tachycardia
Answer: C. Maternal hypoglycemia
A nurse is preparing to administer an IV medication to a patient 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- chemo drug it is hazardous
B. Ampicillin sodium
C. Metronidazole
D. Phenytoin
Answer: A. Doxorubicin hydrochloride- chemo drug it is hazardous
A nurse is reviewing the medication administration record of a patient who has rheumatoid
arthritis and is 1 day postoperative following a left total hip arthroplasty. Which of the
following medication places the patient at risk for delayed wound healing?
A. Omeprazole
B. Morphine
C. Prednisone (steroid)
D. Digoxin
Answer: C. Prednisone (steroid)
A nurse is an emergency department is reviewing the medical record of a patient who is having
an acute myocardial infarction. Which of the following findings places the patient at risk if he
receives alteplase?
A. Hip arthroplasty 1 week ago
B. Family history of malignant hypertension
C. Chronic obstructive pulmonary disease
D. Acute renal failure 6 months ago
Answer: A. Hip arthroplasty 1 week ago
A nurse is caring for a patient who has permanent drooping on the left side of the face
following a cerebrovascular accident (CVA). The patient refuses to see any family members.
Which of the following interventions will best assist the patient to adapt to this body image
change?
A. Establish short-term goals that will enable the patient to look in a mirror
B. Offer contact information for CVA recovery support groups
C. Initiate a family conference to address the issue
D. Educate the patient about short- and long-term effects of a CVA
Answer: A. Establish short-term goals that will enable the patient to look in a mirror
A nurse is teaching the parent of an infant who hospositional plagiocephaly. Which of the
following statements by the parent indicates an understanding of the teaching?
A. “I should avoid tummy time when my baby is wearing the helmet”
B. “I should place my baby in the left side-lying position at night when using the helmet”
C. “I should keep the helmet on my baby for 23 hours a day” (18-22 hours a day)
D. “I should expect to have my baby wear this helmet for 10 months”
Answer: C. “I should keep the helmet on my baby for 23 hours a day” (18-22 hours a day)
A nurse manager is updating protocols for the use of belt restraints. Which of the following
guidelines should the nurse include?
A. Remove the client’s restraints every 4 hr- its every 2 hours
B. Document the client’s condition every 15 min
C. Attach the restraint to the bed’s side rails
D. Request a PRN restraint prescription for clients who are aggressive X
Answer: B. Document the client’s condition every 15 min
A nurse is assessing a patient who has fine hair, exophthalmos, and reports intolerance to heat.
Which of the following endocrine disorders is associated with these findings?
A. Hyperparathyroidism
B. Hyperthyroidism
C. Hypoparathyroidism
D. Hypothyroidism
Answer: B. Hyperthyroidism
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 patient who is at risk for falls
Answer: C. Administering potassium via IV bolus
A nurse in an acute care facility is caring for four clients. Which of the following clients should
the nurse refer for speech therapy?
A. A patient who has dysphagia following a stroke
B. A patient who has sensorineural hearing loss
C. An older adult patient who has stage III Alzheimer’s disease
D. A patient who is postoperative following a tonsillectomy and adenoidectomy
Answer: A. A patient who has dysphagia following a stroke
A nurse is assessing patient who has hypervolemia. Which of the following findings should the
nurse expect?
A. Bounding pulse
B. Bradycardia
C. Decreased blood pressure
D. Urinary frequency
Answer: A. Bounding pulse
A nurse is assessing a patient who is experiencing a pulmonary embolism. Which of the
following manifestations should the nurse expect?
A. Hypertension
B. Frothy sputum
C. Bradycardia
D. Dyspnea
Answer: D. Dyspnea
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 patient in expressing alternative behaviors
Answer: B. Establish the responsibilities of the nurse and client
A nurse is providing nutritional teaching for an older adult patient who hasseizure disorder and
a new prescription of phenytoin. Which of the following instructions by the nurse is
appropriate?
A. “You should expect a change in the color of your stool while taking this medication”
B. “Plan to take this medication with antacids”- not within 2-3 hours
C. “Limit foods that contain folic acid while taking this medication”
D. “Increase your intake of vitamin D while taking this medication” D
Answer: A. “You should expect a change in the color of your stool while taking this
medication”
A nurse is caring for a group of clients. The nurse should recognize that which of the clients is
at greatest risk for developing acute poststreptococcal glomerulonephritis?
A. An 18-year-old girl who is in the second trimester of pregnancy
B. A 16-year-old boy who has appendicitis
C. A 2-month-old girl who has pyloric stenosis
D. A 7-month-old boy who is recovering from impetigo- PSG develops after an infection
caused by bacteria group A Strep. This includes strep throat and impetigo. CC
Answer: D. A 7-month-old boy who is recovering from impetigo- PSG develops after an
infection caused by bacteria group A Strep. This includes strep throat and impetigo. CC
A nurse is caring for a patient 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
A nurse is caring for a patient 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”
A nurse is caring for a patient in an inpatient facility who tells the nurse that she is leaving
because the facility policy prohibits smoking inside. Which of the following actions should the
nurse take?
A. Place the patient in seclusion
B. Call the provider for discharge prescription
C. Notify security to monitor the facility’s exits
D. Inform the patient of the risks involved if she leaves
Answer: D. Inform the patient of the risks involved if she leaves
A nurse is providing an in-service about the patient evacuation during a fire. Which of the
following clients should the nurse instruct the staff to evacuate first?
A. A patient who has a fracture and is in balance suspension traction
B. A patient who is bedridden and wears a hearing aid
C. A patient who uses a wheelchair and is confused
D. A patient who is ambulatory and receiving oxygen
Answer: D. A patient who is ambulatory and receiving oxygen
A nurse is caring for a patient who has Crohn’s disease. Which of the following diagnostic
procedures should the nurse plan to teach the patient regarding pernicious anemia?
A. Schilling test (b12 deficiency test- determines ow well they are able to absorb)
B. Thyroid scan
C. Oral glucose tolerance test
D. D-dimer test
Answer: A. Schilling test (b12 deficiency test- determines ow well they are able to absorb)
A nurse is providing dietary teaching to a patient 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 – dairy
C. Sweeten foods with fructose corn syrup
D. Consume food high in bran fiber- high fiber
Answer: D. Consume food high in bran fiber- high fiber
A nurse is teaching a patient who is at 41 weeks of gestation about a non stress test. Which of
the following information should the nurse include in the teaching?
A. “You will need blood work before and after the test”
B. “You should avoid eating or drinking for 4 hours before the test”
C. “You will have a Doppler transducer applied to your abdomen during the test”
D. “You should massage one of your nipples to stimulate contractions of your uterus”
Answer: C. “You will have a Doppler transducer applied to your abdomen during the test”
A nurse is creating a plan of care for a patient who is postoperative following acoronary artery
bypass graft (CABG). To prevent complications of cardiac surgery, which of the following
instructions should the nurse include in the plan of care?
A. Prepare for fluid volume replacement if the central venous pressure steadily increases
B. Administer atropine to the patient if tachycardia is present
C. Maintain the indwelling urinary catheter until the patient is ready for discharge
D. Check the client’s hemoglobin level if chest tube drainage is 300 mL in the first 1 hr – more
than 150 is hemmorhage
Answer: D. Check the client’s hemoglobin level if chest tube drainage is 300 mL in the first 1
hr – more than 150 is hemmorhage
A nurse in an acute care mental health facility is placing a patient in seclusion and restraints.
Which of the following actions should the nurse plan to take?
A. Have provider evaluate the patient in person within 1 hr- provider must assess within 1 hour
B. Complete a written record regarding the seclusion and restraint every 2 hr
C. Plan to monitor the patient every 30 min while restrained X Q2H
D. Ensure that the prescription for restraints be renewed every 6 hr- renewedQ24H
Answer: A. Have provider evaluate the patient in person within 1 hr- provider must assess
within 1 hour
A nurse is caring for a child who has just been admitted to the acute care medical unit. Which
of the following laboratory findings should the nurse recognize as indicative of rheumatic
fever?
A. Decreased myoglobin and antinuclear antibody titer
B. Decreased Hgb and platelet count
C. Elevated creatine kinase and troponin- FOR MI
D. Elevated sedimentation rate and C-reactive protein -esr measures inflammation.
Answer: D. Elevated sedimentation rate and C-reactive protein -esr measures inflammation.
A nurse is reviewing a client’s laboratory values. Which of the following should the nurse
review to evaluate the client’s nutritional status?
A. Erythrocyte sedimentation rate
B. Troponin level
C. Serum sodium
D. Serum albumin
Answer: D. Serum albumin
A nurse is teaching a patient who is trying to conceive. Which of the following should the
nurse instruct the patient to increase in her diet to prevent a neural tube defect?
A. Folate
B. Zinc
C. Iron
D. Calcium
Answer: A. Folate
A nurse in an emergency department is receiving report for four clients. Which of the following
clients should the nurse see first?
A. A patient who reports frequent and painful urination
B. A patient who reports left arm pain following a fall
C. A patient who has heart failure and received a diuretic 30 min ago
D. A patient who has hypertension and reports a severe headache -seizure or stroke
Answer: D. A patient who has hypertension and reports a severe headache -seizure or stroke
A nurse is reviewing the laboratory results of a patient who has osteomye litis and is receiving
tobramycin. Which of the following findings indicate the patient is experiencing an adverse
effect of the medication?
A. BUN 30 mg/dL
B. Serum creatinine 0. 4 mg/dL
C. Albumin 3. 2 g/dL
D. Total bilirubin 0. 08 mg/dL
Answer: A. BUN 30 mg/dL
A nurse is completing an admission assessment for a patient who has narcissistic personality
disorder. Which of the following findings should the nurse expect? Narcissistic worry about
themselves, fantasies about their ultimate success, power, brilliance and beauty
A. Ritualistic behavior- ocd
B. Suspicious of others-schitzo
C. Exhibits separation anxiety dependant
D. Preoccupied with aging
E. None of the others make sense with perfectionism
Answer: D. Preoccupied with aging
A mental health nurse is caring for a patient who recently attempted suicide. The client states,
“I wish I was dead. ” Which of the following is an appropriate response by the nurse?
A. “Did you take your medications today?”
B. “Suicide is not the answer to your problems”
C. “Don’t worry. Everything will be just fine”
D. “You seem like you’re feeling hopeless”
Answer: D. “You seem like you’re feeling hopeless”
A nurse is reviewing the medical records of four clients. The nurse should identify that which
of the following patient findings requires follow up care?
A. A patient who received a Mantoux test 48 hr ago and has an induration (could be positive
for TB, when you have an induration is has to be measured and they should probably have a
blood test or chest x-ray to confirm TB)
B. A patient who is scheduled for a colonoscopy and is taking sodium phosphate X fine it is a
bowel cleanser
C. A patient who is taking warfarin and has an INR of 1. 8 (Therapeutic 2. 0-3. 0)Low INR
means blood is coagulating and risk for developing a clot, may be compared to TB this isn’t
too bad
D. A patient who is taking 3 and has a potassium level 3. 6 mEq/L X fine
Answer: A. A patient who received a Mantoux test 48 hr ago and has an induration (could be
positive for TB, when you have an induration is has to be measured and they should probably
have a blood test or chest x-ray to confirm TB)
A nurse is caring for a patient who has undergone a modified radical mastectomy. The patient
has a closed-suction drain. Which of the following actions should the nurse take?
A. Secure the drain to the bedding
B. Position the affected extremity below the level of the client’s heart
C. Maintain the patient in supine position for the first 24 hr
D. Reset the vacuum by compressing the container
Answer: D. Reset the vacuum by compressing the container
A nurse is planning to administer 2 units of packed RBCs to an older adult patient who has
anemia. Which of the following actions should the nurse plan to take?(Select all that apply)
A. Assess the client’s lung sounds prior to the infusion
B. Prime the infusion tubing with 0. 45% sodium chloride (0. 9% ONLY)
C. Don sterile gloves to prepare the blood administration setup (I think just clean gloves should
be fine, never heard sterile- it just says maintain a sterile technique during the transfusion but
not the set up)
D. Infuse the blood over 4 hr
E. Verify with another nurse that the unit of blood is compatible with the client’s blood type
Answer: A. Assess the client’s lung sounds prior to the infusion
D. Infuse the blood over 4 hr
E. Verify with another nurse that the unit of blood is compatible with the client’s blood type
A nurse is caring for a patient who has a Clostridium difficile infection. Which of the following
actions should the nurse take? (Select all that apply)
A. Change gloves after contact with infectious material
B. Wear a gown when providing care
C. Wash hands with an alcohol-based cleaner- wash hands with soap and water
D. Remove the thermometer from client’s room for use on another patient – leave the stuff in
the room for each patient
E. Wear an N95 respirator when providing care- this is only for air borne precautions
Answer: A. Change gloves after contact with infectious material
B. Wear a gown when providing care
A community health nurse receives a referral for a family home visit. Which of the following
tasks should the nurse perform first?
A. Schedule a time for the home visit
B. Implement the nursing process
C. Clarify the source of the referral
D. Contact the family by phone
Answer: C. Clarify the source of the referral
A nurse in a maternal newborn unit is admitting a patient who is in labor and at 38 weeks of
gestation. The patient has a history of herpes simplex virus 2. Which of the following questions
is most important for the nurse to ask the client?
A. “Do you have an active lesion?”
B. “Are you currently taking acyclovir?”
C. “When did your labor begin?”
D. “How long ago were you first diagnosed?”
Answer: A. “Do you have an active lesion?”
A nurse is monitoring for complication for a client who is receiving IV potassium chloride.
Which of the following electrocardiogram image should the nurse identify as indicating
potassium toxicity?
A. Peaked T waves following the QRS complex
B. Flat or inverted T waves
C. Prolonged QT interval
D. Presence of U waves
Answer: A. Peaked T waves following the QRS complex
A nurse is caring for a 3-day-old newborn who has a congenital heart defect. Which of the
following interventions should the nurse include to decrease cardiac demands for the newborn?
must conserve the child’s energy, frequent rest periods, cluster care, small frequent meals,
A. Encourage the infant’s parents to limit visitation and physical touch I’m sure parents
visiting soothes the baby
B. Maintain the infant’s temperature at 37 C (98. 6 F) doesn’t say anything about temp, plus
the normal infant temp is 97. 7- 98. 9
C. Keep the infant’s bed in a flat position X maintain semi-flower’s when awake
D. Feed the infant when she is awake and crying keep crying to a minimum also, allow the
infant to rest during feedings
Answer: D. Feed the infant when she is awake and crying keep crying to a minimum also,
allow the infant to rest during feedings
