ATI Comprehensive EXIT EXAM Study Guide
ATI proctored comprehensive study guide practice questions. All versions of exams. STUDY THIS! Nursing School exit exam
Bible EXIT 2021 SPRING 1
VERSION 1
1) A nurse is suctioning the airway of a client who is receiving mechanical ventilation via an
endotracheal tube. Which of the following findings should the nurse identify as an indication
that the suctioning has been effective?
• Presence of a productive cough
• Decrease peak inspiratory pressure
• Flattening of the artificial airway cuff
• Thinning of mucus secretions
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• Speak assertively to the client
• Express sympathy for the client's situation
• Confront the client about this behavior
• Stand within 30 cm of the client when speaking with them
3) A nurse is caring for a client who is immediately postoperative following an adrenalectomy to
treat Cushing's disease. Which of the following actions is the nurse's priority?
• Monitor the client’s fluid and electrolyte status
• Observe for any indications of infection
• Reposition a client for comfort every 2 hours
• Document amount and color of the incision and drainage
4) A nurse realizes that the wrong medication has been administered to a client. Which of the
following actions should the nurse take first?
• Notify the provider
• Report the incident to the nurse manager
• Monitor vital signs
• Fill out an incident report
• You have the right to refuse the procedure
• Your doctor thinks the surgery is necessary
• Let me review the procedure so you can understand what is going to happen
• We can manage your care following the procedure without complications ‘
• Decreased clinging behavior
• Impulsive behaviors
• Lability of mood
• Dependent behavior
7) A nurse is teaching a group of school-age children about healthy snack options. Which of the
following snacks should the nurse include?
• Air popped popcorn
• Baked potato chips
• Milkshake made with whole milk
• Cheesecake
• Store the glasses in a labeled case
• Clean the glasses with hot water
• Clean the glasses with a paper towel
• Store the glasses on the bedside table.
9) A nurse is caring for a client who has fibromyalgia and requested pain medication. Which of the
following medications should the nurse plan to administer?
• Pregabalin (Lyrica) - Nerve Pain Med
• Lorazepam
• Colchicine
• Codeine
10) A nurse is caring for a client who has congestive heart failure and is receiving furosemide
and digoxin. Which of the following laboratory values indicates that the client is at risk for
developing digoxin toxicity?
• Potassium 3.1
• Glucose 150
• Magnesium 1.3 (Magnesium is 1.7 to 2.2)
• Sodium 134
11) A nurse is caring for a client who has an embolic stroke and has a new prescription for
alteplase. Which of the following in the client's history should the nurse identify as a
contraindication to receiving alteplase?
• Hip arthroplasty one week ago
• Acute kidney failure 6 months ago
• Obstructive lung disease
• Retinal detachment
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• I will wear loose clothing over my ICD
• I can hold my cell phone on the same side of my body as ICD
• I will avoid using my microwave oven at home because of the ICD
• I will soak in the tub rather than showering
13) A nurse is assessing a client who is postoperative following abdominal surgery and has an
indwelling urinary catheter that is draining dark yellow urine at 25 ml an hour. Which of the
following interventions should the nurse anticipate?
• Obtain a urine specimen for culture and sensitivity
• Initiate continuous bladder irrigation
• Administer a fluid bolus
• Clamp the catheter tubing for 30 minutes
• Offer to take pictures of the newborn for the client
• Avoid talking to the client about the newborn
• Discourage the client from allowing friends to see the newborn
• Assured a client that she can have additional children
• Maintain consistent hand washing by the staff
• Place a client in protective isolation
• Use sterile dressing for wound care
• Apply topical antibiotics to the client's wounds
16) A nurse is planning care for a client who sustained a major burn over 20% of the body.
Which of the following interventions should the nurse include is important to support the
client’s nutritional requirements?
• Schedule meals at 6 hr
• Keep a calories amount for foods and beverages
• Provide low-protein, high carbohydrates diet
• Maintain the calories intake as 1,500 per day
17) A nurse is speaking with a caregiver of a client who has Alzheimer's disease. The caregiver
states, providing consistent care is very stressful and is affecting all areas of my life. Which of
the following actions should the nurse take?
• Assist the caregiver to arrange for daycare program for the client
• Recommend allowing the client to have time alone in their room throughout the day
• Discuss methods of how to communicate with the client about resolving problem behaviors
• Suggest that the caregiver seek a prescription for an antipsychotic medication for the client
18) A nurse is caring for a client who is one hour postpartum and is unable to urinate. Which of
the following actions should the nurse take?
• Place the clients hands in warm water
• Administer a benzodiazepine
• Performing a fundal massage
• Place an ice pack on a client's perineum
19) A nurse in a medical-surgical unit is performing medication reconciliation for a newly admitted
client. Which of the following actions should the nurse take?
• Compare the clients list of home medications to the admission prescriptions written for the client
20) A nurse is preparing to administer betamethasone to a client who is at 25 weeks of gestation
and has preterm labor. Which of the following findings should the nurse identify as an adverse
effect of this medication?
• Hyperglycemia
21) A nurse is preparing to obtain a blood sample from a client who has a central venous
catheter. Which of the following actions should the nurse take? (Select all that apply)
• Flush the catheter with 0.9% sodium chloride
• Aspirate for blood return to access catheter patency
• Access the catheter using a large bore needle
• Apply force when resistance is met while flushing the catheter
• Apply a tourniquet above the catheter insertion site
• Explain in simple terms how the procedure will affect the child
• Limit teaching sessions about the procedure to 20 minutes
• Instruct the child in deep breathing methods prior to the procedure
• Ask the parents to wait outside the room during the procedure
23) A nurse is performing wound care for a client who has an abdominal incision. Which of
the following should the nurse implement?
• Irrigate the wound with a low pressure flow of solution
• Cleanse the wound starting at the bottom and moving upward
• Irrigate the wound using a 10 ml syringe
• Cleanse the insertion site of the drain using a circular motion toward the center
• A client who has preeclampsia and reports a persistent headache
• A client who is at 28 weeks of gestation and reports leukorrhea
• A client who is at 36 weeks of gestation and has a biophysical profile score of 8
• A client who has pregestational diabetes mellitus and an hba1c of 6.2%
• The client has two small children at home
• The client lives in a two-story home (ehhh maybeishh but i still think A cz she has legs)
• The client's parents is in a Skilled Nursing Facility
• The client is allergic to penicillin
26) A nurse is caring for a client who has major depressive disorder. The client tells the nurse, no
one cares about me. I'm completely alone. Which of the following responses should the nurse
make?
• “Can you give me an example of how others are making you feel this way?”
• “Don't worry. You should be feeling better in a couple of weeks.”
• “What makes you think that?”
• “You should join a community support group.”
27) A nurse is caring for a client who has sustained a severe head trauma and has significant
bleeding from the nose. Which of the following actions should the nurse take first?
• Establish a patent airway
• Insert a peripheral IV line
• Prepare for a CT scan
• Apply direct pressure to the nose
• Place a handrail in the entryway of the house
• Place a towel on the floor outside of the shower
• Ensure that all area rugs are rubber backed (no rugs because they can slip)
• Wear slippers with cloth soles
29) A nurse is caring for a client who is postoperative following total hip arthroplasty. Which of the
following actions should the nurse take to prevent dislocation of the prosthesis?
• Keep an abduction pillow between the clients leg
• Children who have varicella are contagious until vesicles are crusted
• Sit with the client to provide a sense of security
• Administer a dose of atomoxetine to decrease anxiety
• Encourage the client to watch television
• Teach the client how to meditate
• Uses a mechanical lift device to move a client from the bed to the chair
• Stands with feet together when lifting a client up in bed
• Places a gait belt around a client's upper chest before assisting a client to stand
• Raises a client's head of bed before pulling the client up
33) A nurse is teaching a client about condom use. Which of the following client statements
should the nurse identify as an understanding of the teaching?
• I can store the condoms in the drawer of my nightstand
34) 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?
• Peripheral neuropathy
35) A charge nurse is recommending a postpartum client for discharge following a local disaster.
Which of the following clients should the nurse recommend for discharge first?
• A client who delivered precipitously 36 hours ago and has a second-degree perineal laceration
• 42 year old client who has preeclampsia and a blood pressure of 166/110 mmHg
• A 15 year old client who delivered via emergency cesarean birth 1 day ago
• A client received two units of packed RBC's 6 hours ago for a postpartum hemorrhage
36) A nurse is preparing the body of a client who has died for the family to view. Which of the
following actions should the nurse take?
• Place a pillow under the clients head
• Remove the clients dentures
• Place the clients arms across their chest
• Remove the client identification tags
37) 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 into the box on the
right)
• 1. Unlock the handle by pulling on the PIN
• 2. Point the hose at the base of the fire
• 3. Squeeze the handles together
• 4. Sweep the extinguisher from side to side
38) A nurse is reviewing legal issues in healthcare with a group of newly licensed nurses.
Which of the following recommendations should the nurse make?
• Ensure that each client has a living will prior to treatment
• Obtain personal professional liability insurance coverage
• Place copies of incident reports in client's medical records
• Overestimate clients acuity to prevent short staffing
• Review the facility policy about the use of an interpreter
• Direct attention toward the interpreter when speaking to the client
• Request an interpreter of a different sex from the client
• Request a family member or friend to interpret information for the client
40) A nurse in the emergency department is caring for a client following a motor vehicle
crash. Which of the following findings should the nurse identify as a manifestation of
hypovolemic shock?
• Change in level of consciousness
• Hyperactive deep tendon reflexes
• Decrease respiratory rate
• Increase urine output
• Palpate the pulse distal to the cast
• Teach the client to keep the cast clean and dry
• Position the casted extremity on a pillow
• Place an ice pack over the cast
42) A nurse is performing a gait assessment on a client to evaluate the client's ability to perform
ADL's. Which of the following findings indicates a standard gait?
• The client's heels touch the ground before their toes
• The client looks at the floor when walking
• The clients dominant foot Bears more weight
• The client shoulders are rounded slightly forward
43) A nurse in a mental health unit is caring for a client who has suicidal ideation. Which of the
following actions should the nurse take?
• Establish a no suicide contract with the client
44) A nurse is providing teaching about nutrition therapy to a client who is experiencing anorexia
due to chemotherapy treatment. Which of the following statements should the nurse make?
• Add grated cheese to vegetable dishes
• Avoid adding butter to foods
• Snack frequently on fresh fruit
• Add water to soups to increase volume
45) A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus
about administering NPH and regular insulin together in one injection. Which of the following
instructions should the nurse include?
• Draw up regular insulin prior to NPH
• Roll the syringe gently to ensure mixture of the insulins
• Inject into the vastus lateralis
• Use a 15 degree angle for the injection
46) A nurse is caring for a client who has a calcium level of 8 mg. Which of the following
actions should the nurse take?
• Place the client on a seizure precaution
• Place a client on a low calcium diet
• Request a prescription for magnesium citrate
• Request a prescription for furosemide
47) A nurse is caring for a client who has schizophrenia and is experiencing delusions. Which of
the following actions should the nurse take?
• Encourage the client to rest quietly in bed twice per day
• Avoid assessing the clients delusions
• Direct long conversations about the delusions toward reality based topics
• Allow the client unlimited time to discuss the delusions when they occur
• “Taking furosemide can cause your potassium levels to be high”
• “Eat foods that are high in sodium”
• “Rise slowly when getting out of bed”
• “Taking furosemide can cause you to be overhydrated”
49) A nurse is conducting a health promotion class about the use of oral
contraceptives. Which of the following disorders is a contraindication for oral
contraceptive use?
• Hypertension
• Fibrocystic breast condition
• Fibromyalgia
• Asthma
• Client who has hypertension and reports chest pain
• Client who has a compound fracture of the femur
• Client who has a deep laceration on both sides
• Client who has severe abdominal pain
• Gather supplies prior to completing a dressing change
• Complete partial assessments on all clients before planning the day
• Prioritize activities based on the nurses needs
• Use break time to perform documentation
52) A nurse in a mental health unit is planning room assignments for four clients. Which of
the following should the nurse assign to a room near the nurses station?
• A client who has a depressive disorder and reports feeling hopeless
• A client who has an anxiety disorder and is experiencing moderate anxiety
• A client who has bipolar disorder and impaired social interactions
• A client who has a somatic symptom disorder and reports chronic pain
53) A nurse is preparing to measure the temperature of an infant. Which of the following actions
should the nurse take?
• Place the tip of the thermometer under the center of the infant’s axilla
• Pull the pinna of the infant’s ear forward before inserting the probe
• Insert the probe 3.8 cm (1.5 in) into the infant’s rectum
• Insert the thermometer in front of the infant’s tongue
54) A nurse is assessing coping strategies of a client whose partner has alcohol use disorder.
Which of the following findings indicates that the client is coping effectively?
• The client attends regular counseling sessions
• The client utilizes strategies to enhance codependent behaviors
• The client exhibits sympathy for the partner
• The client ignores their partner when they are using alcohol
55) A nurse is caring for a client who has Graves’ disease and is experiencing a thyroid storm. Which
of the following actions is the nurse's priority?
• Monitor the client's cardiac rhythm
• Obtain a client's blood glucose
• Provide a cooling blanket
• Administer 0.9% sodium chloride IV
56) A nurse is providing preoperative teaching to a client about promoting circulation during the
postoperative period. Which of the following instructions should the nurse include?
• Participate in range of motion exercises
• Use an incentive spirometer every 4 hours
• Place a pillow under your knees while in bed
• Remain on bed rest for 24 hours following the procedure
• Remove the cap and place it sterile side up on a clean surface
• Place sterile gauze over areas of spilled solution within the sterile field
• Hold a bottle in the center of the sterile field when pouring a solution
• Hold the irrigation solution bottle with the label facing away from the palm of the hand
• Contact Child Protective Services
• Refer the parent to a self-help group
• Document clinical findings
• Instruct the parents about methods of discipline
59) A nurse in a clinic is reviewing the health history of a client during her first prenatal visit.
Which of the following findings indicates a risk for gestational diabetes mellitus?
• BMI of 31
• Delivery of a low-birth-weight infant
• Previous miscarriage
• 1 hour oral glucose tolerance test of 128 mg
• Position the client laterally at 30 degrees
• Have two faculty personal help to slide the client up in bed
• Apply lotion to the skin every 4 hours
• Reposition the client every 3 hours
• Evaluate a client's understanding at regular intervals
• Use clients children to provide interpretation
• Offer clients translation services for a nominal fee
• Direct questions to a medical interpreter (Maybe but i think it is A)
• Bring in formula as needed
• Stock the room with a 2 day supply of disposable diapers
• Leave the unused infusion pump in the room until discharge
• Return unopened equipment to the supply center
63) A nurse is caring for a client who has acute exacerbation of multiple sclerosis. Which of the
following prescriptions should the nurse expect the provider to prescribe?
• Interferon beta-1a
• Atorvastatin
• Enoxaparin
• Amoxicillin
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• Respite care
• Restorative care
• Rehabilitation facility
• Hospice
65) A nurse is assessing a school-age child who has moderate dehydration due to diarrhea and
vomiting. Which of the following manifestations should the nurse expect?
• Orthostatic hypotension
• Decrease respirations
• Bradycardia
• Polyuria
66) A nurse is caring for a client who is at 14 weeks of gestation and reports feeling of
ambivalence about being pregnant. Which of the following responses should a nurse make?
• “Describe your feelings to me about being pregnant.”
• “When did you start having these feelings?”
• “Have you discussed these feelings with your partner?”
• “You should discuss your feelings about being pregnant with your provider.”
67) A nurse manager is planning to promote client advocacy among staff on a medical unit. Which
of the following actions should the nurse plan to take?
• Develop a system for staff members to report safety concerns in the client care environment
• Tell staff to explain procedures to client's before obtaining informed consent
• Encourage staff to implement the principle of paternalism when a client is having difficulty
making a choice
• Instruct unit staff to share personal experiences to help clients make decisions
68) A nurse receives a telephone call from a parent reporting that the school each child has a
nosebleed and that they cannot stop the bleeding. Which of the following instructions
should the nurse provide to the parent?
• Use your thumb and forefinger to apply pressure to the sides of your child's nose
• Place a warm, wet washcloth over your child's forehead and the bridge of their nose
• Tell your child to blow their nose gently, and then sit down and tilt their head backwards
• Have your child lie down and turn their head to the side for 10 minutes
69) 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?
• Match the client’s blood type with the type and crossmatch specimens
• Confirm the provider’s prescription matches the number on the blood component
• Ask the client to state the blood type and the date of their last blood donation
• Ensure that the client’s identification band matches the number on the blood unit
--- PRETTY SURE it is D….. IDENTIFY PATIENT
70) A nurse is assessing a client who has a Stage IV pressure ulcer and is undergoing treatment
prescribed by a wound care consultant. For which of the following findings should the nurse
contact the consulting to revise the plan of care?
• Weight loss of 5% in 10 days
• HGB 15
• Albumin level 4.0 g
• Appearance of pink tissue under eschar
• Inject 20 ml of air and aspirate in the NG Tube
• Check the functioning of the suction equipment
• Reposition the NG Tube
• Instill an irrigation solution slowly
72) A nurse is caring for a client who has major depressive disorder. Which of the following
findings should indicate to the nurse that the client's condition is improving?
• The client experiences self-doubt when making decisions
• The client exhibits a flat affect
• The client participates in self-care
• The client avoids eye contact with others
client, which
• Provide a client with an instructional handout about swallowing exercises
• Discuss the manifestations of impaired swallowing with the AP
• Ask a speech therapist to evaluate the client's ability to swallow
• Listen to the clients lung sounds
74) 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 client who has depressive disorder and requires assistance with ADLs
• A client who has obsessive compulsive disorder and is upset about a change in daily routine
• A client who is taking clozapine to treat schizophrenia and reports a sore throat
• A client who has narcissistic personality disorder and is mocking others during group therapy
75) A charge nurse is educating a group of unit nurses about delegating client tasks to assistive
personnel. Which of the following statements should the charge nurse include in the teaching?
• The RN evaluates client needs to determine tasks to delegate
• The RN is legally responsible for the actions of the AP
• An experienced AP can delegate tasks to another AP
• An AP can perform tasks out of his range of function if he has been trained
76) A nurse in an emergency department is caring for a client who reported cocaine use 1 hour
ago. Which of the following findings should the nurse expect?
• Elevated temperature
• Memory loss
• Slurred speech
• Hypotension - NO
77)
• Report this client finding to the provider
• Request a prescription for an opioid pain medication for the client
• Administer an additional dose of ibuprofen to the client
• Ask the client to rate their pain on a scale of 0 to 10
78) A nurse is planning care for an older adult client who has dementia. Which of the following
interventions should the nurse include in the plan of care? (Select all that apply)
• Give the client one simple direction at a time
• Reinforced orientation to time, place, and person
• Establish eye contact when communicating with the client
• Refuse the client solutions using logic
• Allow the client to choose among a variety of activities each day
• This medication will prevent seizures during your withdrawal from alcohol
• Alcohol should not be consumed for 3 days following your last dose
• Wait at least 12 hours after your last drink to take this medication
• This medication will decrease your risk for delirium during your withdrawal from alcohol
80) A nurse is assessing a client following an ischemic stroke. Which of the following findings is the
priority for the nurse to report to the provider?
• The client reports a decreased appetite
• The client has poor fitting dentures
• The client reports a metallic taste in his mouth
• The client coughs after swallowing
81) A nurse is creating a plan of care for a client who has paranoid personality disorder and
refuses to take their medication. Which of the following interventions should the nurse include
in the plan?
• Limit the clients opportunities to socialize with others
• Speak in neutral tone when addressing the client
• Rotate staff members caring for the client
• Mix the medication with the clients food items
82) A nurse is assessing a client immediately following a cardiac catheterization. The nurse
should notify the provider for which of the following findings?
• Report of discomfort at the insertion site
• Bounding pulses in the affected extremity
• Hematoma over insertion site
• Heart rate 90/min
83)
• Ensure that the client checks the gauge weekly
• Place the oxygen tank away from curtains or drapes
• Store the oxygen tank wrench in a locked cabinet
• Have the client store smaller tanks under his bed
84) A nurse is providing discharge teaching to a client following a total hip arthroplasty. Which of
the following statements by the client indicates an understanding of the teaching?
• I will bend at the hips when tying my shoes
• I will start my leg exercises three days after returning home
• I don't need to use a walker when walking around my house
• I won't cross my legs when sitting in the chair
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• Monitor for an increase in the occurrence of hiccups
• Move slowly when standing from a sitting position
• Expect loose stools as an adverse effect
• Anticipate an increase in salvation production
86) A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate.
The client reports that she is experiencing difficulty breathing. Which of the following
actions should the nurse take first?
• Obtain a client's magnesium level
• Administer calcium gluconate
• Discontinue the infusion
• Assess the fetal heart rate
87) A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a
kidney transplant. Which of the following findings should the nurse report to the provider?
• Urine pH 6.2
• Serum creatinine 1.6 mg/dL
• Urine specific gravity 1.023
• BUN 18 mg/dL
88) A nurse is caring for a client who is on fall precautions. Which of the following actions
should the nurse take?
• Establish an elimination schedule for the client
• Raise all four bed rails on the client's bed
• Silence the bed alarm when visitors are at the client's bedside
• Allow the client to walk unassisted near the nursing station
• Ask security to detain the client until the provider is notified
• Shows the client her abnormal laboratory results
• Asks the client to sign a form releasing the hospital from legal responsibility
• Asks the client what her plans are for follow-up care
90) A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone
(SIADH). Which of the following nursing interventions should the nurse include in the plan of
care for this client?
• Weigh the client weekly
• Perform neurologic checks
• Encourage oral hydration of 1800 mL daily
• Flush IV tubing with hypotonic solution
• Critical Pathways have an unlimited time frame for completion
• Critical pathways should reduce healthcare costs
• Nurses should discontinue the critical pathway if variances occur
• Nurses notes are used to create the critical pathway
92) A nurse is providing teaching to a client who has otitis media and is 1 hour postoperative
following a myringotomy. Which of the following statements should the nurse include in a
teaching?
• You should expect excessive ear drainage for about 48 hours (maybe)
• You should blow your nose with your mouth closed
• You should not drink through a straw for two weeks
• You can wash your hair 3 days after the procedure
• “They are mandatory government documentation.”
• “They assist the faculty to achieve benchmark goals.”
• “They are used as a disciplinary tool for nurse evaluations.”
• “They assist with unit quality improvement.”
94) A nurse is assessing a newborn who has a blood glucose level of 30 mg/dL. Which of the
following manifestations should the nurse expect?
• Loose stools
• Jitteriness
• Hypertonia
• Abdominal distention
95) A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should
the nurse plan to take?
• Obtain the newborn’s body temperature using a tympanic thermometer
• (Unable to read) FACES pain scale
• Auscultate the newborn’s apical pulse for 60 seconds
• Measure the newborn’s head circumference over the eyebrows and below the occipital
prominence
96) A nurse is caring for a client who has experienced a stroke and is moving in with their adult
child. Which of the following actions should the nurse encourage the client and family to take
as they adjust to their new roles?
• Minimize open discussion regarding the changes to avoid embarrassment
• Encourage authoritative communication from the adult child
• Decrease socialization with extended relatives until roles are identified
• Implement firm but flexible boundaries in their relationship
• Massage reddened areas over bony prominences
• Maintain the head of the bed at 45 angle
• Provide a high fiber diet for the client
• Ask the client to shift his weight every 20 minutes while sitting in a chair
98) A nurse in a provider's office is reviewing the laboratory results of a group of clients. The
nurse should identify which of the following sexually transmitted infections is a nationally
notifiable infectious disease that should be reported to the State Health Department?
• Chlamydia
• Herpes simplex virus
• Human papillomavirus
• Candidiasis
99) A nurse is caring for a client who is postpartum and requests information about
contraception. Which of the following instructions should the nurse include?
• You should avoid vaginal spermicides while breastfeeding
• Place a transdermal birth control patch on your upper outer arm
• You can continue to use a diaphragm you use before your pregnancy
• The lactation amenorrhea method is effective for your first year postpartum
• Report of pain level of 5 on a scale of 0 to 10
• Passage of small clots
• Burgundy colored urine
• Urgency to void
101) A nurse is caring for a client who is receiving enteral feedings through a nasoenteric
tube and has aspirated fluid prior to a feeding. Which of the following findings should
indicate to the nurse that the tube is positioned in the client's lung?
• Residual fluid with a pH of 1
• Residual fluid with a pH of 8
• Residual fluid with a pH of 3
• Residual fluid with a pH of 6
• Prone
• High Fowler's
• Right lateral
• Trendelenburg
103) A nurse is caring for a client who is receiving brachytherapy for endometrial cancer.
Which of the following actions should the nurse take?
• Keep visitors at least six feet away from the client
• Discard the radioactive Source in the client's trash can
• Wear a isolation gown when caring for the client
• Place the clients soiled bed linens in a biohazard bag outside the clients room
104) A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary
recommendations should the nurse make?
• Coffee with creamer
• Lettuce with sliced avocados
• Broiled skinless chicken breast with brown rice
• Warm toast with margarine
• Speech language pathologist
• Dietitian
• Occupational therapist
• Physical therapist
106) 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?
• Morphine 3.0 mg Sub-Q every 4 hours PRN for pain
• Morphine 3 mg subcutaneous every 4 hours PRN for pain
• Morphine 3 mg SQ every 4 hours PRN for pain
• Morphine 30 mg Sc q 4 hours PRN for pain
• Wear sterile gloves to collect the specimen from the client
• Ask the client to provide 15 to 20 ml of sputum into the container
• Wait one day to collect the specimen if the client cannot provide sputum
• Obtain the specimen immediately upon the client waking up
• I can use a firm pillow to prop up the bottle when feeding my baby
• I will hang a pastel-colored mobile 24 in above my baby's crib
• I will avoid picking up my baby too often to keep from spoiling him
• I will place a ticking clock nearby to soothe my baby throughout the day
• Provide high protein nutritional supplements
• Schedule a large meal in the evening
• Offer hot fluids along with meals
• Encourage the client to eat toast for breakfast
• I can remove my baby's identification band as long as she is in my room
• Staff will apply identification bands to my baby after her first bath
• I can leave my baby in my room while I walk in the hallway
• I will not publish a public announcement about my baby's birth
111) A nurse is providing prenatal teaching to a client who is at 12 weeks of gestation. The nurse
should tell the client that she will undergo which of the following screen tests at 16 weeks of
gestation?
• Cervical cultures for chlamydia
• Chorionic villus sampling
• Non stress test
• Maternal serum alpha fetoprotein
112) A nurse is providing nutritional teaching about appropriate food choices to a client who has a
new diagnosis of uric acid calculi. Which of the following foods should the nurse include in the
teaching?
• Liver
• Roast beef
• Lima beans
• Chicken
113) A nurse in a mental health facility is caring for a client who is experiencing a panic level of
anxiety. Which of the following actions should the nurse take?
• Have the client Journal about what is happening to him
• Encourage the client to talk about his feelings
• Tell the client to sit alone in a private place and reflect on the situation
• Use short sentences when communicating with the client
• Advance directives can include a do not resuscitate order signed by the provider
• An attorney will need to review your advance directives
• A healthcare surrogate will handle your medical bills
• A family member will need to co-sign the advance directives document
115) A nurse is caring for an adolescent who has sickle cell anemia. Which of the following
manifestations indicate an acute chest syndrome and should be immediately reported to the
provider?
• Sneezing
• Temperature 37.9 degrees
• Hematuria
• Substernal retractions
116) A nurse is caring for a client who has a tension pneumothorax. Which of the following
manifestations should the nurse expect?
• Asymmetry of the chest
• Blood-tinged sputum
• Bilateral crackles
• Paradoxical chest movement
117) A nurse is caring for a client who is at 11 weeks of gestation. Which of the following
immunizations should the nurse recommend?
• Human papillomavirus
• Varicella
• Influenza
• Measles mumps and rubella
118) A nurse in a pediatric clinic is reviewing the laboratory test results of a school-age child.
Which of the following findings should the nurse report to the provider?
• WBC 14,000/mm3
• HCT 40%
• HGB 12.5 g/dL
• Platelets 250,000/mm3
• Low back pain
• Hypotension
• Dyspnea
• Thready pulse
120) A nurse is providing discharge teaching for a group of clients. The nurse should
recommend a referral to a dietitian
• A client who has a prescription for warfarin and states “I will need to limit how much spinach I
eat”
• A client who has gout and states, “I can continue to eat anchovies on my pizza”
• A client who has a prescription for spironolactone and states “I will reduce my intake of foods
that contain potassium”
• A client who has (Unable to read) and states “I’ll plan to take my calcium carbonate
with a full glass of water”
121) A nurse is caring for an adult client who asks about risk factors for Alzheimer's disease.
Which of the following responses should the nurse make?
• “There are no known genetic mutations that cause Alzheimer's disease”
• “Asthma has been identified as a risk factor for Alzheimer's disease”
• “Repeated concussions increase the risk for Alzheimer's disease”
• “A diet low in carbohydrates increases the risk for Alzheimer's disease”
122) A community health nurse is developing a plan to improve the community's
environmental health. Which of the following actions should the nurse take first?
• Encourage Community involvement in Environmental Improvement
• Request funding from Community organizations
• Collect information about the communities environmental status
• Establish a time frame for environmental improvements
123) A nurse is planning teaching for a client who has a new diagnosis of HIV. Which of the
following information should the nurse include about preventing the spread of the infection?
• Use condoms with a petroleum-based lubricant
• Clean blood contaminated surfaces with bleach
• Buy disposable dishes for daily use
• Wash soiled clothes in cold water
124) A charge nurse is teaching a newly licensed nurse about medication administration. Which of
the following information should the charge nurse include?
• Inform clients about the action of each medication prior to administration
• Reading medication labels at least two times prior to administration
• Avoid preparing medications for more than two clients at one time
• Completes an incident report if a client vomits after taking a medication
125) A nurse is teaching about preventing sudden infant death syndrome to a parent of a one
month old infant. Which of the following images indicates that the parent understands how to
place the infant in the crib at bedtime? THIS IS A PICTURE
• The infant is laying on their back. There's nothing in the crib. There are no pillows.
126) A nurse in a pediatric clinic is assessing a six-month-old infant. Which of the following
findings should the nurse identify as a possible indication of neglect?
• Lack of social smile
• Current weight twice the infant's birth weight
• A capillary hemangioma on the buttocks
• Inability to sit without support
127) A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has
questions about the disease. to research the disease, the nurse should identify which of the
following electronic databases has the most comprehensive collection of nursing Journal
article?
• CINAHL
• ProQuest
• Health Source
• Medline
128) A nurse in a provider's office is assessing a client for a melanoma. Which of the following
findings should the nurse report to the provider?
• Red blue papule on the upper back
• Round, light tan pigmented spots on the face
• Red, pustular lesions on the face
• Circular, brown plaques on the arms
129) A nurse is assessing a client who has a brain tumor and is receiving palliative care. Which of
the following findings indicates the nurse should administer pain medication?
• Constricted pupils ----------it would be dilated if in pain
• Mottled skin
• Restlessness
• Cheyne's Stokes respirations
130) A nurse is obtaining the temperature of a newborn. Which of the following sites should the
nurse use?
• Rectal
• Oral
• Tympanic
• Axillary
131) A nurse is preparing to administer Vancomycin IV to an adult client. The client asks the
nurse if the medication can be given two hours earlier. Which of the following statements
should the nurse make?
• I can Infuse the medication at a faster rate
• I can adjust the time and schedule for when it's convenient for you
• I have up to two hours after the usual schedule time to give you this medication
• I can start the medication 30 minutes earlier
132) A nurse is preparing to insert an IV catheter for a client. Which of the following actions
should the nurse plan to take?
• Apply a tourniquet below the venipuncture site
• Elevate the client's arm prior to insertion
• Choose a vein that is palpable and straight
• Select a site on the client's dominant arm
133) A nurse is planning care for a client who has unilateral paralysis and dysphagia following
a right hemisphere stroke. Which of the following interventions should the nurse include in
the plan?
• Provide Total Care in performing the clients ADL's
• Place the clients left arm on the pillow while he is sitting
• Maintain the client on bed rest
• Place food on the left side of the client's mouth when he is ready to eat
134) The steps of progressive discipline process prior to counseling the staff member who
exhibits unprofessional behavior. (Move the steps into the box in the order)
• 1. Verbally remind a staff member of the expected behavior changes
• 2. Set up a meeting to speak with the staff member about the behavior
• 3. Give the staff member a written warning about the behavior
• 4. Suspend the staff member from work for several days
• 5. Dismiss the staff member from employment at the faculty
• Take tub baths instead of showers
• Drink at least one liter of fluid every day
• Try to void every 4 hours
• Wipe from back to front after a bowel movement
136) A nurse is caring for a newly admitted client who has a history of expressive aphasia.
Which of the following actions should the nurse take?
• Speak loudly while facing the client
• Provide the client with an artificial voice box
• Apply a safety monitoring device on the client's bed
• Use a picture board to communicate with the client
137) A nurse in a long-term care facility is caring for a client who has Alzheimer's disease. The
client's partner asks why the client started taking memantine instead of donepezil. Which of the
following responses should the nurse make?
• Memantine improves cognitive function in later stages of Alzheimer's
• Memantine is an herbal alternative to donepezil
• Memantine is an extended release version of donepezil
• Memantine helps prevent seizures in clients who have Alzheimer's
138) A nurse overhears two assistive personnel discussing care for a client while in the elevator.
Which of the following actions should the nurse take?
• File a complaint with the faculties ethic committee
• Report the incident to the AP's charge nurse
• Contact the client's family about the incident
• Notify the client's provider about the incident
139) A nurse is teaching a client who has AIDS and is immunosuppressed about food safety.
Which of the following information should the nurse include in the teaching?
• Store perishable foods in the refrigerator at 8.9 C
• Plan to eat poultry within 3 days of refrigeration
• Eat leftover food within 5 to 7 days of preparation
• Defrost frozen foods in the refrigerator before preparation
• Once a DNR order has been implemented, it cannot be changed
• The presence of a DNR order indicates that there is no conflict between the client and the
family's wishes
• A client can verbally request a DNR order from the provider
• A DNR order indicates that the client cannot be prescribed new medications or treatments
141) A nurse is teaching a group of clients who are planning to have bariatric surgery. Which of
the following statements by the client indicates an understanding of the teaching?
• I should wait 30 minutes after eating solid foods to drink beverages following surgery
• I will need to lose 25% of my excess body weight prior to surgery
• I should reduce my daily calorie intake by 250 calories to lose 2 lbs each week after surgery
• I will consume 48 oz of carbonated beverages daily prior to the surgery
• Structure audit
• Outcome audit
• Concurrent audit
• Prospective audit
143) A charge nurse is assigning a client care test for the upcoming shift. Which of the
following tasks should the charge nurse assign to an RN?
• Inserting an epidural catheter
• Obtaining blood cultures from a central catheter
• Inserting an endotracheal tube
• Performing a thoracentesis
144) A nurse is assessing a client who is on bed rest and notes one calf is 2.5 cm larger in
diameter than the other calf. Which of the following actions should the nurse take?
• Massage the larger calf
• Restrict the client's fluid intake
• Apply a warm, moist soak to the larger calf
• Place the client's legs in a dependent position
145) A nurse is caring for a client who is in labor and receiving oxytocin. Which of the following
findings indicates that the nurse should increase the rate of infusion?
• Contractions every 5 minutes that last 30 seconds
• Montevideo units consistently 300 mmHg ---- should not exceed 250
• FHR pattern with absent variability
• Urine output of 20 ml/hr
146) A nurse is screening food brought in by a family member for a client who takes
phenelzine. The nurse should instruct the family member that which of the following foods
can cause an interaction with this medication?
• Iceberg lettuce salad
• Orange gelatin
• Bologna sandwich
• Cottage cheese
- Phenelzine is a MAOI
147) A quality control nurse is reviewing medication prescriptions for a group of clients. Which of
the following medication prescriptions should the nurse identify as being complete?
• Cimetidine PO twice daily
• Epoetin Alfa 150 units kg three times weekly
• Tetracycline 200 mg PO
• Digoxin 0.25 mg PO daily
148) 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?
• Use three prong grounded plugs
• Cover extension cords with a rug
• Check the tingling sensations around the cord to ensure the electricity is working
• Remove the plug from the socket by pulling the cord.
• Ask the client to explain his understanding of the procedure
• Inform the client of his right to change his mind
• Notify the provider if the client has questions about the procedure
• Witness the client sign the informed consent form
150) A nurse is planning care for a client who has terminal cancer and is nearing the end of life.
Which of the following interventions should the nurse include?
• Speak in a loud tone when addressing the client
• Place the client in a supine position
• Offer the client a blanket to keep warm
• Remind the client to eat scheduled meals daily
151) A nurse is assessing a five-year-old child who has diabetes insipidus and is receiving
desmopressin. Which of the following findings should the nurse identify as an indication that
the medication is effective?
• Absence of hypoglycemic episodes
• Cessation of nocturnal enuresis
• Capillary refill 3 seconds
• Heart rate 140/min
152) A nurse in an emergency department is caring for a client who received a dose of penicillin
and is now anxious, flushing, tachycardic, and having difficulty swallowing. Which of the
following actions is the nurse's priority?
• Monitor the client's ECG
• Administer oxygen
• Take the client's vital signs
• Insert an IV line
153) A nurse is caring for an adolescent who has ADHD. Which of the following findings
should the nurse report to the provider? (Exhibit button for additional information about
the client)
• Oxygen saturation
• Aspartate aminotransferase AST - normal is 8 to 33 … exhibit shows 82
• Weight
• WBC count
154) A nurse is reviewing the medical record of a client who is postoperative following a total hip
arthroplasty. For which of the following findings should the nurse contact the provider?
• WBC count 14,000/mm3
• Albumin level 4.0 g/dL
• Heart rate 100/min
• Temperature 37.8 C (100 F)
155) A nurse is teaching a client who has chronic pain about avoiding constipation from opioid
medications. Which of the following information should the nurse include in the teaching?
• Take mineral oil at bedtime
• Drink 1.5 L of fluids each day
• Decrease insoluble fiber intake
• Increase exercise activity
156) A nurse is administering scheduled medication to a client. The client reports that the
medication appears different from what they take at home. Which of the following responses
should the nurse make?
• I will call the pharmacist now to check on this medication
• Do you know why this medication is being prescribed for you
• Did the doctor discuss with you that there was a change in this medication
• I recommend that you take this medication as prescribed
157) A nurse is admitting an adolescent who has rubella. Which of the following actions should the
nurse take?
• Monitor for the development of koplik spots
• Isolate a client from staff who are pregnant
• Administer aspirin to the client
• Initiate airborne precautions
158) A nurse is teaching the parents of a school-age child who is newly diagnosed with juvenile
idiopathic arthritis. Which of the following interventions should the nurse include in the
teaching?
• Have the child take a tub bath each morning
• Keep the child on bed rest as long as pain persists
• Encourage the child to take naps during the day
• Apply splints to the child's extremities during the day
159) A nurse is providing teaching about the administration of gastrostomy tube feedings to the
parents of a school-age child. Which of the following instructions should the nurse include?
• Place the child in a Supine position after the feeding
• Warm the formula in the microwave prior to Administration
• Administer the feeding over 30 minutes
• Change the feeding bag and tubing every 3 days
160) A nurse is caring for a client who has a fracture of the left hip and is in skeletal traction.
Which of the following actions should the nurse take?
• Remove the traction weights when bathing the client (avoid lifting or removing weights)
• Increase the amount of weight if the client experiences muscle spasms (can’t do this)
• Ensure there is no space between the traction weights and the bed
• Provide a trapeze for the client to aid movement in bed
• I am glad I am available today, but when I am not, you can use a family member
• I will let the client know that an interpreter is unavailable during the night shift
• I will let the client know that I am available as an interpreter
• I will receive a small fee for interpreting for this client
• While eating, you should drink liquids frequently
• Lunch should be your largest meal of the day
• During meals, you should eat foods with a high calorie content first
• You should eat hot foods to reduce your sense of fullness during a meal
163) A nurse is teaching a client who has GERD and a new prescription for Omeprazole delayedrelease capsules. Which of the following statements by the client indicates an understanding of
the teaching?
• I can expect to have black tarry stools while taking this medication
• I should decrease my calcium intake while taking this medication
• I can expect my hands to have tremors while taking this medication
• I should take this medication before my first meal of the day
164) A charge nurse is observing a newly licensed nurse insert an indwelling urinary catheter
for a female client. Which of the following actions by the nurse requires intervention by the
charge nurse?
• Opens the sterile kit by unfolding the flap closest to her first
165) A nurse is providing teaching to an older adult client who has seizure disorder and a new
prescription for phenytoin. Which of the following instructions should the nurse include?
• Limit foods that contain vitamin D while taking this medication
• Limit foods that contain folic acid while taking this medication
• Plan to take this medication with food - Mickey takes keppra with food - same shit (um with
CHEESE specifically put some respect on his name goddamn)- i will never forget this question:)
• Plan to take this medication with antacids
166) A client is requesting information from a nurse about a nitrazine test. Which of the following
statements should the nurse make?
• The test will determine if there is leaking amniotic fluid
• Your bladder should be full prior to me performing this test
• If this test is positive you will be required to have a non-stress test
• I will be taking a blood sample to test for changes in your hormone levels
1
• Aspirin
• Acetaminophen
• Ibuprofen
• Naproxen sodium
168) A nurse is providing teaching about crutch safety to a client. Which of the following
client actions indicates an understanding of the teaching?
• The client places that crutches 30 cm to the front and side of each foot while standing
• The client flexes her elbows 10 when supporting weights by using the hand grips
• The client keeps her axillae free of pressure
• The client leans on both crutches to support body weight
• Erythrocyte sedimentation rate 75 mm
• Aspartate aminotransferase 10 units
• WBC count 8000
• Platelets 150,000
170) A nurse is assessing a client who has received an antibiotic. The nurse should identify which
of the following findings as an indication of a possible allergic reaction to the medication?
• Joint pain
• Headache
• Hypotension
• Bradycardia
171) A nurse is planning care for a client who has a chest tube. Which of the following
interventions should the nurse include in the plan? (Select all that apply)
• Strip the chest tube vigorously to dislodge blood clots
• Clamp the chest tube every 2 hours to assess amount of drainage
• Mark the drainage output on the collection chamber hourly
• Add water to the water seal chamber as it evaporates
• Maintain the collection of chamber above the level of the clients waist
• Agnosia
• Confabulation
• Projection
• Perseveration
173) A nurse is caring for a client who is 1 hour postoperative following a thoracentesis. Which of
the following alterations in the client's condition should the nurse identify as an indication of
the development of pneumothorax?
• Pallor
• Slow respirations
• Tracheal deviation
• Bradycardia
174) A nurse is providing care for a patient who has depression and is to have electroconvulsive
therapy. Which of the following conditions should the nurse identify as increasing the client's
risk for complications?
• Diabetes mellitus
• Renal calculi
• Hyperthyroidism
• Cardiac dysrhythmias
• Serotonin syndrome
• Tardive dyskinesia
• Pseudo parkinsonism
• Acute dystonia
176) 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?
• Platelets 100,000/mm3
177) A nurse is caring for a client who is experiencing cerebral edema. Which of the following
actions should the nurse take?
• Place the client in a prone position
• Perform multiple nursing care activities at one time
• Assess the client for positive trousseau sign
• Administer corticosteroids
178) A nurse is caring for a school-age child who has sickle cell anemia and is experiencing a
vaso-occlusive crisis. Which of the following actions should the nurse take?
• Place the child on bed rest
• Apply cold compresses to the child's joints
• Administer meperidine to the child
• Decrease the child oral fluid intake
179) A nurse is teaching a client who is to undergo placement of a non-tunneled percutaneous
central venous access device. Which of the following statements should the nurse include in
the teaching?
• Your head will be elevated as high as possible while the catheter is inserted
• The provider will give you pain medications before inserting a catheter
• The provider will wear a mask while performing the procedure
• You should not eat or drink for 4 hours prior to the procedure
180) A nurse is collecting medication history from a client who reports taking aspirin 81 mg daily.
Which of the following medications place the client at increased risk for bleeding?
• Pioglitazone
• Dabigatran
• Potassium chloride
• Gabapentin
VERSION 2
1. A nurse is assessing a client who has bipolar disorder and is experiencing a depressive
episode. Which of the following findings should the nurse expect?
• Inability to carry out a simple task
2. A nurse is caring for a client who has colon cancer and is terminally ill. The client states “I can’t
believe I am going to die.” Which of the following statements should the nurse make?
• “Tell me what is important to you right now”
3. A nurse is performing an initial assessment of a newborn. Which of the following actions should
the nurse take to prevent any heat loss through conduction?
• Place the newborn's crib away from an air vent to perform the assessment - CONVECTION
- Evaluate respirations by observing the newborn’s uncovered chest for 1 minutes
- Cover the scale with a warmed blanket before weighing the baby
- Perform the assessment immediately after birth before removing amniotic fluid
4. The steps of progressive discipline process prior to counseling the staff member who
exhibits unprofessional behavior. (Move the steps into the box in the order)
• 1. Verbally remind a staff member of the expected behavior changes
2. Set up a meeting to speak with the staff member about the behavior
3. Give the staff member a written warning about the behavior
• 4. Suspend the staff member from work for several days
• 5. Dismiss the staff member from employment at the faculty
5. 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 include?
• Allow the client enough time to perform rituals
6. A nurse in a community clinic is caring for a client who requests assistance with smoking
cessation. The nurse should expect a prescription for which of the following medications?
• Bupropion
7. A client’s partner tells a staff nurse that he overhears laboratory staff discussing the result of the
client's biopsy report while on the elevator. Which of the following actions should the nurse take?
• Report the information to the charge nurse
8. 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?
• Frothy, pink sputum
9. A nurse is creating a plan of care for a female client who has recurrent urinary tract
infections. Which of the following interventions should the nurse include in the plan?
• Wear loose fitting underwear
10.The nurse is caring for a client recovering from an acute myocardial infarction. Which of the
following interventions should the nurse include in the point of care?
• Obtain a cardiac rehabilitation consultation
11.A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary
recommendations should the nurse make?
• Broiled skinless chicken breast with brown rice
12.A nurse on a mental health unit is admitting a client who has post-traumatic stress disorder.
Which of the following findings should the nurse expect?
• Has difficulty concentrating on a task
13.A nurse is assessing a client who is receiving packed RBCs. Which of the following
findings indicates fluid overload?
• Dyspnea
14.A nurse is preparing to administer levothyroxine 50 mcg to a client. Available is
levothyroxine 0.025 mg/tablet. How many tablets should the nurse administer?
• 2 tablets
15.A nurse is reviewing the laboratory results of a client and notes increased values for
hemoglobin, hematocrit, and urine osmolarity. The nurse should identify that these results are
manifestations of which of the following client conditions?
• Dehydration
16.A nurse is admitting a client who has dementia to a long-term care facility. The client tells the
nurse that she lived in this facility years ago and took care of all the residents by herself. The
nurse should document this as which of the following findings?
• Confabulation
17.A nurse is reviewing assessment data for several clients. For which of the following clients
should the nurse recommend referral to a dietitian?
• A client who has a non-healing leg ulcer
18.A nurse is caring for a client who received a large amount of heparin IV in error. Which of the
following laboratory values should the nurse obtain?
• aPTT
19.A nurse and an assistive personnel are assigned to a group of clients on the unit. Which of the
following clients should the nurse instruct the AP to report to the nurse?
• A client who has a prescription for compression stockings and did not receive them
20.A nurse is caring for a client who has vision loss. Which of the following actions should the nurse
take? (Select all that apply)
• Keep objects in the client’s room in the same place
• Ensure there is high-wattage lighting in the client’s room
• Allow extra time for the client to perform tasks
21.A nurse manager is reviewing documentation with a newly licensed nurse. Which of the following
notations by the newly licensed nurse indicates an understanding of the teaching?
• OOB(out of bed) with assistance for breakfast
22.A nurse is verifying a record of informed consent for a client who is scheduled for surgery. Which
of the following actions should the nurse take?
• Confirm the client’s signature is authentic
23.A nurse is caring for a client who has diaper dermatitis. Which of the following actions should
the nurse take?
• Apply zinc oxide ointment to the irritated area
24.A newly licensed nurse is unsure if an assigned task is within their scope of practice. Which of the
following resources should the nurse consult?
• State nurse practice act
25.A nurse is caring for a client who is near the end of life and is on complete bed rest. The client
states that he needs to have a bowel movement and the nurse offers a bedpan. The client states,
“I’ve always used the bathroom.” Which of the following responses should the nurse make?
• “Tell me what concerns you have about using a bedpan”
26.A nurse is teaching a client who had a left below the knee amputation 3 days ago. The nurse
should identify which statement by the client indicates an understanding of teaching?
• “I might still experience the feeling of numbness and tingling in my left foot”
27.A nurse is caring for a client who is in the advanced stage of amyotrophic lateral sclerosis.
Which of the following referrals is the nurse's priority?
• Speech language pathologist
28.A nurse is caring for a client who has acute exacerbation of multiple sclerosis. Which of the
following prescriptions should the nurse expect the provider to prescribe?
Interferon beta-1a •
29.A nurse is caring for a client admitted for alcohol use disorder who reports using alcohol to deal
with stress. Which of the following actions should the nurse take to assist the client in
maintaining self-control of the behavior?
• Give positive feedback to the client for using adaptive coping strategies
30.A nurse is providing discharge instructions about newborn safety to a client who is 2 days
postpartum. Which instructions should the nurse include?
• Use a car seat when traveling by airplane
31.A nurse is preparing to administer eye drops to a school aged child. Identify the actions the nurse
should take. (Place the steps in order)
• 1. Place child in sitting position
• 2. Ask the child to look upward
• 3. Pull the lower eyelid downward
• 4. Instill the drops of medication
• 5. Apply pressure to the lacrimal punctum
32.A nurse is consulting a pharmacological reference about medication compatibility prior to
administering warfarin to a client. Which of the following medications should the nurse identify
as being incompatible with warfarin?
• Naproxen
33.A nurse is providing dietary teaching to a client who had an exacerbation of COPD. Which of the
following information should a nurse include in the teaching?
• During meals, you should eat foods with a high calorie content first
34.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?
• Morphine 3 mg subcutaneous every 4 hours PRN for pain
35.A nurse is reviewing the laboratory report of a client who has been receiving 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?
• Administer the medication
- Normal levels are 0.4-1.4, so go ahead
36. A nurse is planning care for a school-age child who is 4 hr postoperative following perforated
appendicitis. Which of the following actions should the nurse include in the plan of care?
• Administer analgesics on a scheduled basis for the first 24 hr
37. A nurse in an emergency department is caring for a client following a motor vehicle crash. The
client’s Glasgow coma scale reading is 15 which of the following findings should the nurse
expect
• The client is oriented times 3
38.A nurse is caring for a client who requests the creation of a living will. Which of the
following actions should the nurse take?
• Evaluate the client’s understanding of life-sustaining measures
39. A community health nurse is developing a plan to improve the community's environmental
health. Which of the following actions should the nurse take first?
• Collect information about the communities environmental status
40.A nurse is performing gastric lavage for a client who has upper gastrointestinal bleeding.
Which should the nurse do?
• Insert large bore NG tube
41. A nurse is providing teaching to a client who is experiencing preterm contractions and
dehydration. Which of the following statements should the nurse make?
• “Dehydration can increase the risk for preterm labor”
42.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?
• Erythrocyte sedimentation rate 75 mm/hr (0-29 mm/hr)
43.A nurse is planning care for four clients who are at risk for fluid imbalances. The nurse
should identify which client is at risk for fluid volume excess?
• A client who has advanced stage liver cirrhosis
44.A nurse is giving an intramuscular injection to a newborn who was delivered at 38 weeks’
gestation. Which pain scale should the nurse use to assess the newborn's pain?
• Neonatal infant pain scale (NIPS)
45.A nurse managers planning to promote client advocacy among staff on the medical unit.
Which of the following actions should the nurse plan to take?
• Develop a system for staff members to report safety concerns in the client care environment
46.A nurse is providing discharge instructions to a client who has a new prescription for
spironolactone. Which of the following instructions should the nurse include in the teaching?
• Take the medication in the morning
47.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?
• I will avoid food beverages that contain caffeine
48.A nurse is caring for a client who has heart failure. The nurse notes the client's 24 hour intake is
1750 mL and output is 425 mL. Which of the following actions should the nurse take first?
• Compare the client’s weight to the previous day
49.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?
• Performing tracheostomy care
50.A nurse is assessing a client who is 30 min postoperative following an arterial
thrombectomy. Which of the following findings should the nurse report?
• Chest pain
51.A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a
prescription for parenteral fluid therapy. The guardian asks. “What are the indications that my baby
needs an IV?” Which of the following responses should the nurse make?
• “Your baby needs an IV because she is not producing any tears”
52.A nurse is caring for a client who has compartment syndrome following the application of a cast
on the leg. Which action should the nurse take?
• Check the clients pedal pulses
53.A nurse is reviewing the cardiac rhythm of a client who is continuous ECG monitoring. Which
of the following findings is an indication of ventricular tachycardia?
• QRS complexes wider than 0.15 seconds
54.A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the
nurse plan to take?
• Auscultate the newborn’s apical pulse for 60 seconds
55.A nurse is administering scheduled medication to a client. The client reports that the medication
appears different from what they take at home. Which of the following responses should the nurse
make?
• I will call the pharmacist now to check on this medication
56.A nurse is assessing the grief response of a client whose child died 6 months ago. Which of the
following statements should prove to the provider as an indication of a major depressive
disorder?
• “I am unable to feel any joy since my child died”
57.A charge nurse is assigning client care tasks for the upcoming shift. Which of the following tasks
should the nurse assign to the RN?
• Obtaining blood cultures from central catheter
58.A nurse is preparing to administer an IV medication to a client and accidentally 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 bio-hazardous material spill?
• Doxorubicin hydrochloride
- Chemotherapy drug
59.A nurse is caring for an adolescent who has sickle cell anemia. Which of the following
manifestations indicate an acute chest syndrome and should be immediately reported to the
provider?
• Substernal retractions
60.A nurse is providing discharge teaching for a group of clients. The nurse should recommend a
referral to a dietitian
• A client who has gout and states, “I can continue to eat anchovies on my pizza”
61.A nurse is planning care for a client who has neutropenia due to leukemia. Which of the
following interventions should the nurse include in the plan of care?
• Screen the child’s visitors for active infections
62.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?
• Teaching parenting skills to expectant mothers and their partners
63.A charge nurse is recommending a postpartum client for discharge following a local disaster.
Which of the following clients should the nurse recommend for discharge first?
• A client who delivered precipitously 36 hours ago and has a second-degree perineal laceration
64.A nurse is teaching a client about using a 3-point gait for crutch-walking. Which of the
following actions by the …the teaching?
• Uses both crutches when advancing the affected leg
65.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?
• Balancing the bottle on the sterile basin while pouring the liquid
66.A nurse is teaching a group of clients who are planning to have bariatric surgery. Which of the
following statements by the client indicates an understanding of the teaching?
• I should wait 30 minutes after eating solid foods to drink beverages following surgery
67.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?
• Ensure that the client’s identification band matches number on the blood unit
68.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?
• Use three pronged grounded plugs
69.A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions
about the disease. To research the disease, the nurse should identify which of the following
electronic databases has the most comprehensive collection of nursing Journal articles?
• CINAHL
- (Cumulative index to nursing and allied health literature)
70.A nurse is caring for a client who is recovering from an amputation of her right arm below the
elbow. Which of the following information should the nurse report to the occupational therapist?
• The client lives in a two-story home
• The client has two small children at home (maybe)
71.A nurse is caring for a client who has cancer of the throat and is receiving radiation therapy. The
nurse should monitor for which findings as an adverse effect of the radiation?
• Altered taste sensation
72.A nurse is providing teaching about patient-controlled analgesia (PCA) to a client. Which of the
following statements should the nurse include in the teaching?
• “You should push the button before physical activity to allow maximum pain control”
73.A nurse is caring for a client who has gestational hypertension and is experiencing toxic effects
due to magnesium sulfate therapy. The nurse should anticipate administering which of the
following medications?
• Calcium gluconate
74.A nurse is providing teaching to a client who has multiple sclerosis. Which of the following
statements should the nurse include in the teaching?
• Avoid exercises that increase your body temperature
75.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?
• Speak assertively to the client
76.A nurse is caring for a client receiving mechanical ventilation via an endotracheal (ET) tube. The
high pressure alarm is beeping and the client is experiencing respiratory distress. The nurse is
unable to determine the cause of the alarm. Which of the following actions should the nurse take?
• Deliver breaths manually with a resuscitation bag
77.A community health nurse is reviewing laboratory reports for a group of clients. The nurse
should identify which of the following disorders is on the CDC nationally notifiable conditions
list?
• Lyme disease
78.A nurse is admitting a client who does not speak the same language as the nurse and is
scheduled for outpatient surgery. Which of the following actions should the nurse take?
• Explain the procedure to the client through an interpreter
79.A charge nurse is planning a staff education and competence session about operating newly
acquired cardiac monitoring equipment. Which of the following actions should the nurse plan to
take? (Select all that apply)
• Provide reinforcement of teaching until skill is learned
• Require a return demonstration using the equipment
• Identify the current level of staff knowledge about the equipment
80. A nurse is teaching a client who has chronic low back pain about the use of alternative
therapy to manage pain. Which of the following statements by the client indicates an
understanding of the use of distractions?
• “I will watch my favorite old movies when I want to reduce stress”
81.A nurse in the infectious disease division of the local health department is caring for a client. Which
of the following should be reported to the health department?
• Chlamydia trachomatis
82.A nurse is preparing to admit a client who is 35 weeks of gestation for evaluation of fetal wellbeing due to potential preterm labor. Which of the following pieces of equipment should the
nurse use to evaluate the fetal heart rate?
• Ultrasound transducer
83.A home health nurse is teaching a new parent about caring for his one week old infant. Which of
the following statements by the client indicates an understanding of the teaching?
• I will place a ticking clock nearby to soothe my baby throughout the day
84.A nurse is assessing a client who is immediately postoperative following subtotal
thyroidectomy. The nurse observes tetany. Which medication should the nurse expect to
administer?
• Calcium gluconate
85.A nurse is caring for a client who tells the nurse that he feels he is being discharged from the
facility too soon. Which demonstrates client advocacy?
• “I will tell your provider about your concerns”
86.A nurse is preparing to administer a blood transfusion to a client. Which of the following
actions should the nurse take?
• Prime the tubing with 0.9% sodium chloride
87.A nurse in a clinic is assessing a 6-month-old infant. Which of the following findings should the
nurse report to the provider?
• Closed anterior fontanelle
88.A nurse is providing discharge teaching to a female client who has tuberculosis and a new
prescription for rifampin. Which of the following information should the nurse include?
• “Your urine will be orange while taking this medication”
89.A nurse should obtain a urine specimen from a client who has had an indwelling urinary
catheter for 3 days. Which action should the nurse take after collecting the specimen?
• Place the specimen in a biohazard bag for transport
90.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 by the nurse is therapeutic?
• “Can you talk about what happens with your partner at home?”
91.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 should the nurse include in the teaching?
• Wear gloves when providing care to the client
92.A nurse is teaching a childbirth education class and is discussing sexual intercourse during
pregnancy. Which of the following…should the nurse make?
• “Your sexual desire might increase during the first trimester of pregnancy” OR
- The female superior position can be used during the third trimester of pregnancy
93.A nurse in a surgical clinic is providing teaching to a client who is scheduled for a modified radical
mastectomy. Which statement by the client indicates an understanding of the teaching?
• “I will complete my arm exercises 4 times a day”
94.A nurse is reviewing legal issues in healthcare with a group of newly licensed nurses. Which
of the recommendations should the nurse make?
• Obtain personal professional liability insurance coverage
95.A nurse is caring for a client following application of a cast. Which of the following actions should
the nurse take first?
• Palpate the pulse distal to the cast
96.A nurse in the provider's office is reviewing female clients medical records during a routine visit.
The nurse should recommend increased dietary intake of which of the following vitamins?
Exhibit 1: Warfarin 2.5 mg PO daily; Ferrous gluconate 325 mg PO 4x/day; Multivitamin 1 tab/day
Exhibit 2: INR 2.5; Hemoglobin 11; Urinalysis negative
Exhibit 3: Postmenopausal; hx of DVT and iron deficiency anemia; works indoors; 1-2 alc/week
• Vitamin B12
97.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?
• The group encourages members to focus on a particular issue
98.A nurse is caring for a client who is experiencing acute mania. Which of the following foods should
the nurse provide to the client?
• Peanut butter sandwich
99.A nurse is providing teaching to a client who is scheduled for radiation therapy to treat
esophageal cancer. Which of the following should the nurse make
• “Drink mostly clear liquids”
100. A nurse is caring for a client who has a prescription for 1-unit packed RBC. Five minutes after
beginning the transfusion the client becomes febrile with chills. After stopping the transfusion,
which action should the nurse take?
• Administer epinephrine SQ
101. A nurse is updating the plan of care for a client who has an exacerbation of psoriasis.
Which intervention should the nurse include in the plan?
• Cover lesions with an occlusive dressing after applying a corticosteroid
- It is NOT discontinue ultraviolet light therapy if lesions itchy - just add lotion bitch
102. A nurse is caring for a school-age child who has sickle cell anemia and is in vaso
occlusive crisis. Which of the following actions should the nurse take?
• Increase oral fluid intake
103. A nurse is caring for a client who has bipolar disorder. Which of the following behaviors should
the nurse identify as indicating the client is experiencing mania?
• Client is easily distracted by external stimuli
104. 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?
• Platelet count - when mickey had red spots and a platelet count of 0
105. 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?
• Notify the nursing manager about the suspected alcohol use
106. 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 wants the client to have life sustaining
measures. Which of the following actions should the nurse take?
• Arrange for an ethics committee meeting to address the family’s concerns
107. A nurse is providing teaching to a client who has a new prescription for warfarin. The nurse
should identify which medication can the effects o increase f warfarin?
• Aspirin
108. A nurse is providing teaching to a client who is to begin external radiation therapy for
cancer. What info should the nurse include?
• “You might experience altered taste sensation”
109. A nurse in a mental health clinic received a request from a client who is undergoing
psychotherapy to obtain a copy of the therapist notes. Which of the following responses
should the nurse make?
• “We can provide a copy of your records, but the therapist’s notes are not included”
110. A nurse is caring for an older adult client who has prescriptions for multiple medications. Which
of the following factors should the nurse identify as an age-related change that increases the risk
for adverse effects from medications?
• Prolonged medication half-life
111. A nurse is reviewing the medical record of a client who has delayed healing of a leg ulcer. Which
of the following findings should the nurse identify as a contributing factor?
• The client takes prednisone for arthritis
112. A nurse is providing teaching to a client who is breastfeeding and experiencing
engorgement. Which of the following recommendations should the nurse include
• Apply warm compresses on the breasts before feeding
113. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the
following should the toddler participate?
• Playing with a large plastic truck
114. A nurse is caring for four clients on a medical surgical unit. For which of the following clients
should the nurse complete a reconciliation?
• A client who returns to the unit from the PACU following surgery
115. A nurse is preparing a change of shift report for an adult female client who is
postoperative. Which is the following client information the nurse should include in the
report?
• Platelets 100,000/mm3
116. A nurse is planning care for a client who is postoperative following a total hip arthroplasty. Which
of the following actions should the nurse plan to take when positioning the client?
• Ensure the clients hips remain in an abducted position
117. A nurse in an emergency department is assessing a client who has major depressive
disorder. Which of the following actions should the nurse take first? (Exhibit question)
• Implement seizure precautions for the client
118. A nurse is preparing to obtain a client’s signature on an informed consent form. Which of the
following actions should the nurse take?
• Ask the client to explain his understanding of the procedure
119. A nurse realizes that the wrong medication has been administered to a client. Which action should
the nurse take first?
• Measure the client’s vital signs
120. A nurse is assessing a client who has a prescription for hydrocodone PRN. Which adverse
effect should the nurse identify as a priority for withholding this medication and notifying the
provider?
• Hypotension
121. A nurse is preparing to administer PRN pain meds to a client who has cholelithiasis and is
experiencing moderate abdominal pain. Which medication should the nurse administer?
• Ketorolac
122. Allergy test picture
• A (the client’s back)
123. A nurse is providing dietary teaching to a client who has hyperlipidemia. Which of the
following should the nurse include in the teaching that contains the lowest amount of
saturated fats?
• Canola oil
124. A nurse is calculating a client’s expected date of delivery. The client’s last menstrual period began
on April 12. Using Nagele’s rule, what date should the nurse determine to be the client’s expected
date of delivery (use mm/dd format)
• 0119
125. A nurse is teaching participants at a community center about advance directives. Which of the
following should the nurse include in the teaching?
• A healthcare surrogate makes healthcare decisions when the client is no longer able
126. A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis
following a stroke. Which of the following actions by the nurse promotes communications best
among staff caring for the client?
• Having interdisciplinary team meetings for the client on a regular basis
127. 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?
• Serotonin syndrome
128. A nurse is caring for a client who is in labor and receiving oxytocin. Which of the
following indicates that the nurse should increase the rate of infusion?
• Contractions every 5 min that last 30 sec
129. A nurse is caring for a newborn who is experiencing neonatal abstinence syndrome. Which of the
following actions should the nurse plan to take?
• Decrease the lighting levels in the nursery
130. A 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 contraindication to the
use of the combination oral contraceptives?
• Thrombophlebitis
131. 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?
• Whole grain bread
132. 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?
• “Rise slowly when getting out of bed”
133. A nurse is providing teaching to the parent of a child who has recently inserted a central
venous access device. Which of the following statements by the child’s family member
indicates an understanding of the teaching?
• “If my child develops an elevated temperature, I will contact you”
134. A nurse is caring for an infant who has a respiratory syncytial virus. Which of the
following interventions should the nurse take?
• Administer palivizumab intravenously
135. A nurse is reviewing the formulary about NPH insulin before administering the medication to a
client. Which of the following should the nurse expect?
• Administer NPH insulin 30 min before breakfast
136. A nurse is caring for a client who speaks a language different from the nurse. Which of the
following actions should the nurse take?
• Review the facility policy about the use of an interpreter
137. A nurse is reviewing lab data from a client who has chronic kidney disease (CKD). Which should
the nurse expect?
• Increased creatinine
138. A nurse is helping to prepare a client in the operating room prior to a surgical procedure.
Which of the following actions should the nurse
• Remove the client’s eyeglasses upon arrival to the operating room
139. A nurse in a mental health facility receives a change of shift report on four clients. Which of the
following clients should the nurse plan to assess first?
• Client placed in restraints due to aggressive behavior
140. A nurse is counseling a group of clients from a town that was affected by a hurricane 6 months
ago. For which of the following clients should the nurse initiate a referral to assess for the
presence of post-traumatic stress disorder? (Select all that apply)
• A client who describes having persistent feelings of anger about the hurricane
• A client who has frequent nightmares about the hurricane
• A client who describes feeling disconnected from those around him following the hurricane
141. A nurse is caring for a client who has a pressure injury on the coccyx. Which of the following
findings should indicate to the nurse that the wound is a stage 3 pressure injury?
• Subcutaneous fat is visible
142. A nurse is caring for a client who is receiving continuous enteral feeding. Which of the
following actions should the nurse take? (Select all that apply)
• Change the feeding container and tubing every 24 hr
• Check gastric residuals every 4 hr
• Maintain the head of the clients bed at an 30 angle or higher
143. 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?
• I will position my baby at a 45 degree angle
144. 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?
• Peripheral neuropathy
145. A nurse is assessing a client who has heart failure and is prescribed a 2000 mL per hour fluid
restriction. Which of the following should the nurse report to the provider?
• Urinary output of 420 ml in 8 hr OR
- !"#$%&'(#))*(')+',--'.*'/0'1'2%'3'4$'#2/05'#2/('
146. A nurse is assessing a client who is in skeletal traction for fractured left tibia. The nurse should
identify that which of the following indicates altered tissue perfusion of the affected extremity
• Faint pedal pulse of left leg
147. 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?
• Check the mouth for soot and smoky breath
148. 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?
• Determine goals of the day
149. A nurse is caring for a client who is 12 hr postoperative following aortofemoral bypass surgery.
Which of the following findings should be expected in the affected extremity?
• Pedal pulse of 2+
150. 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?
• Confirm the client’s perception of the event
151. 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?
• Limit the clients visitors to 30 min per day
152. A nurse is planning teaching for a client who has a new diagnosis of HIV. Which of the
following information should the nurse include in preventing the spread of the infection?
• Clean blood contaminated surfaces with bleach
153. A nurse is admitting an older adult client who is transferring from another facility. The nurse
notes pressure injury on the client coccyx and abrasion around both wrists. Which of the
following should the nurse take to address suspicions of elder abuse?
• Privately interview the client about the injuries
154. A nurse is assessing a client who is receiving a daily aspirin therapy. The nurse should
identify which of the following findings might be an allergic reaction to this medication?
• Difficulty swallowing
155. The nurse is preparing to initiate IV therapy for an older adult client. Which plan of action should
the nurse take?
• Apply a tourniquet firmly above the insertion site th 3 is isn’t it, it can cause hematoma and blow the
veins and tear the skin
• Use 22 gauge catheter for insertion 3'#2/('/('/#'
156. A nurse in the emergency department is assessing a newly admitted client who is
experiencing drooling and hoarseness. Which of the following should the nurse take first?
• Apply 100% humidified oxygen
157. The nurse is teaching her client systemic lupus erythematosus (SLE). Which of the following
statements by the client indicates an understanding of teaching?
• I will cleanse my skin using a mild soap
158. A nurse obtains a client’s manual blood pressure and is having difficulty auscultating sounds.
Which of the following actions should the nurse take?
• Use the palpatory method to determine blood pressure
• Pregabalin
160. A nurse is caring for a client who has hypertension and a new prescription for
chlorthalidone. The nurse should monitor for which of the following adverse effects?
• Hypokalemia
161. A nurse is preparing to measure the temperature of an infant. Which action should the nurse
take?
• Place the tip of the thermometer under the center of the infant’s axilla
162. A nurse is caring for a client who wears glasses. Which of the following actions should the
nurse take?
• Store the glasses in a labeled case
163. A newly licensed nurse is reviewing the role of a nurse in disaster planning. Which of the
following is an activity a nurse should engage in to assist in disaster preparedness?
• Participate in community drills and mock events
164. A nurse is assessing a newborn who has a blood glucose level of 30 mg/dL. Which of the
following manifestations should the nurse expect?
• Jitteriness
165. 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 of the use of oxytocin?
• Postterm with oligohydramnios
166. A nurse is initiating bladder retraining for a client who has urge incontinence. Which of the
following instructions should the nurse give the client?
• “Plan to urinate every 3 hrs while you are awake”
167. A nurse is teaching a client who plans to begin following vegan dietary guidelines. Which of the
following information should the nurse give?
• Choose foods high in vitamin B12
168. A nurse administers digoxin 0.125 mg PO to an adult client. For which of the following findings
should the nurse notify the provider
• Apical pulse 58/min
169. A nurse is performing physical therapy for a client who has Parkinson’s disease. Which of
the following statements by the client indicate the need for a referral to physical therapy?
• “Lately, I feel like my feet are freezing up, as they are stuck to the ground”
170. A nurse is providing teaching about home safety to the adult child of an older adult client who is
postoperative following knee replacement surgery. Which of the following instructions should the
nurse include?
• Mark the edges of the doorway to the house with tape
171. 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?
• Administer the feeding over 30 min
172. 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?
• I will not publish public announcement about my baby’s birth
173. A nurse is caring for a client who is postoperative immediately following cardiac
catheterization with a right femoral approach. Which action should the nurse take?
• Assess the client’s peripheral pulses every 15 min
174. A nurse is evaluating the response to the plan of care for a client who is grieving the death of a
partner. Which of the following findings should the nurse identify as indicating that the client is
experiencing maladaptive grieving?
• The client reports feelings of guilt about the partners death
175. A nurse is completing an incident report after a client falls. Which of the following
competencies of Quality and Safety Education for Nurse is the use demonstrating?
• Quality improvement
176. A nurse is admitting a client who has one week postpartum and reports excessive vaginal
bleeding. The nurse does not speak the same language as a client. The client partner and two year
old child or accompanying her. Which of the following actions should the nurse take together with
the client's admission data?
• Request a female interpreter through the facility
177. 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?
• Folate
VERSION 3 – EXTRA STUFF (BASICALLY 2019 C)
1. A nurse in an inpatient eating disorder unit is assessing an adolescent client who has
anorexia nervosa and a BMI of 16.5. Which of the following findings should the nurse
expect?
• Potassium 4.2
• Lanugo
• Menorrhagia
• Blood pressure 132/82
2. A nurse is caring for a client who has diabetes mellitus and is receiving long acting daily insulin
for blood glucose management. The nurse should anticipate administering which of the following
types of insulin?
• NPH insulin
- Intermediate
• Regular insulin
- Short acting
• Glargine insulin
• Insulin aspart
- Short acting
3. A nurse is caring for a client who weighs 75 Kg. The client has a prescription from a dietician to
decrease calorie intake by 500 calories a day to provide weight loss of one pound per week. What
is the expected goal weight for the client in pounds at the end of the 25 weeks? (Round the answer
to the nearest whole number)
• 140 lbs
4. A nurse is preparing to administer Ranitidine 50 mg IV over 15 minutes to a client. Available is ranitidine
50mg in 100 ml 0.9% sodium chloride. The nurse should set the IV pump to deliver how many ml/hr?
• 400 ml/hour
5. A nurse in a clinic is assessing a client who reports frequent headaches. Identify the area the nurse
should palpate to check the clients maxillary sinus for tenderness.
• The image shows a man side profile. C is the correct answer (under the eye)
6. A nurse is preparing to administer esomeprazole 20 mg IV bolus 100 ml of 5% dextrose in water
for a client with peptic ulcer disease. Available is esomeprazole 40 mg / 5 ml. How many
milliliters should the nurse add to the 5% dextrose in water? Round answer to the nearest tenth.
• 2.5 mL
• Ventricular and atrial rate 120 a minute
• Inconsistent P wave formation
• PR interval of 0.30 second (< .20)
• P to QRS ratio of 1:1
• I should focus on eating complex carbohydrates
• I should lie down after my meals
• I should increase my intake of liquids with meals
• I should sip on clear carbohydrates beverages that have gone flat
• Ensure that the electric outlet has two prongs for the IV pump
• Check the of the IV pump for fraying cords
• Grasp the IV pump cord when unplugging it from the electrical outlet
• Remove the safety inspection sticker before plugging in the IV pump
10.A nurse is assessing a 2 year old toddler. Which of the following findings should the nurse
expect?
• Palpate fontanel's
• Natural loss of deciduous teeth
• Head circumference exceeds chest circumference (head circumference is equal tochest)
• Non-tender, protruding abdomen
11.A nurse is providing teaching to a client who is experiencing preterm contractions and
dehydration. Which of the following statements should the nurse make?
• “Dehydration is treated with calcium supplements”
• “Dehydration can increase the risk of preterm labor”
• “Dehydration is associated gastroesophageal reflux”
• “Dehydration is caused by a decreased hemoglobin and hematocrit”
12.A nurse is caring for a client who is receiving oxytocin IV for augmentation of Labor. The client's
contractions are occurring every 1 minute within a 45 Second duration, and the fetal heartbeat is 170 to
180 a minute. Which of the following actions should the nurse take?
• Administer calcium gluconate
• Relieve pressure on the umbilical cord
• Apply an internal fetal heart rate monitor
• Discontinue the oxytocin infusion
• Palpation
• Auscultation
• Inspection
• Percussion
14.A nurse in a mental health unit is caring for a client who has schizophrenia and is experiencing
auditory hallucinations telling them to others. The client is refusing to take anti-psychotic
medication. Which of the following responses should the nurse make?
• This medication will help you respond to the voices
• This medication will help stop the voices you are hearing
• You should plan to take this medication for a few weeks
• You'll regret it if you do not take your medication
• Contractions
• Epigastric pain
• Hypertension
• Vomiting
• Consume food high in bran fiber
• Increase intake milk products
• Increase intake of food high in gluten
• Sweeten food with fructose corn syrup
• Eat a light snack before bedtime
• Stay in bed at least 1 hour if unable to fall asleep
• Perform exercise prior to bedtime
• Take a 1-hour nap during the day
• “Your baby needs an IV because she is not producing any tears''
• “Your baby needs an IV because her fontanels are budging”
• “Your baby needs an IV because she is breathing slower than normal”
• “Your baby needs an IV because her heart rate is decreasing”
19.A nurse is caring for a client receiving intermittent enteral tube feeding. Which of the
following factors places the client at risk for aspiration?
• A history of gastrointestinal reflux disease
• Sitting high fowler's position during the feeding
• A residual of 65 mL 1 hr postprandial
• Receiving high osmolality formula
20.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?
• Confront the nurse about the suspected alcohol use
• Inform another nurse on the unit about the suspected alcohol use
• Ask the nurse to finish administering medications and then go home
• Notify the nursing manager about the suspected alcohol use
• Quality improvement
• Patient (Unable to read)
• Evidence based practice
• Informatics
22.A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the
following actions should the nurse take?
• Perform the procedure twice each day
• Administer a bronchodilator after the procedure
• Hold hand flat to perform percussion on the child
• Perform the procedure prior to meals
• Have your child drink a small glass of water after swallowing the medication
• You can add the medication to a half cup of your child's favorite juice
• Repeat the dose if your child vomits within 1 hour after taking the medication
• Limit your child potassium intake while she is taking this medication
24.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?
• Prime IV tubing with 0.9% sodium chloride
• Use a 24-gauge IV catheter
• Obtain filter less IV tubing
• Place blood in the warmer for 1 hr
• Looking at alphabet flashcards
• Playing with a large plastic truck
• Use scissors cut out paper shapes
• Watching a cartoon in the dayroom.
• Swelling of the face
• Urinary frequency
• Faintness upon rising
• Bleeding gums
27.A nurse is developing an in-service about personality disorders. Which of the following
information should the nurse include when discussing borderline personality disorder?
• “The client exhibits impulsive behavior”
• “The client might act seductively”
• “The client is exceptionally angry to other”
• “The client is overly concerned about minor details”
administration of clozapine?
• WBC count 2,900/mm
• HR 58
• Fasting BG 100
• Hgb 14
• Maternal hypoglycemia
• Maternal fever
• Chorioamnionitis
• Fetal anemia
• Previous violent behavior
• History of being in prison
• Experiencing delusions
• Male gender
• Eat 1g/kg of protein per day
• Consume food high in potassium
- Low potassium
• Drink at least 3 L of fluids daily
- Too much dumbfuck
• Take magnesium hydroxide for indigestion
• Excessive sweating
• Dry cough
• Metallic taste in mouth
• Increased urine frequency
33.A nurse is reviewing the medical records of four clients. The nurse should identify which of
the following client findings requires follow up care?
• A client who received a Mantoux test 48 hours and has a induration
• A client who is scheduled for a colonoscopy and is taking sodium phosphate
• A client who is taking warfarin and has an INR of 1.8
• A client who is taking bumetanide and has a potassium level of 3.6
34.A nurse is caring for a client who has returned to the medical-surgical unit following a
transurethral resection of the prostate. Which of the following should the nurse identify as
priority nursing assessment after reviewing the client's information? (Exhibit question)
• Level of consciousness
• Weak femoral pulses
36.A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following
manifestations requires immediate action by the nurse?
Increase in frequency of swallowing •
37.Flu shot allergy
• Egg
38. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam
tablets (Unable to read) a respiratory rate of 10/min. After securing the client's airway and initiating
an IV, which of the following actions should the nurse do next.
• Preoccupied with aging
• Ritual behavior
• Suspicious of others
• Exhibits separation anxiety
• A client who is 1 day postoperative following a vertebroplasty
• A client who has COPD and a respiratory rate of 44/min
• A client who has cancer with a sealed implant for radiation therapy
• A client who is receiving heparin for deep vein thrombosis
• A client who has a hip fracture and a new onset of tachypnea
4
• Hypertension
• Amputation
• Osteoarthritis
• Primary glaucoma
• A client who has preeclampsia and reports a persistent headache
• A client who is 28 weeks of gestation and report leukorrhea
• A client who has pregestational diabetes and an HbA1c of 6.2%
• A client who is at 36 weeks of gestation and has a biophysical profile score of 8
• Shivering
45.A nurse is caring for a client who has diaper dermatitis. Which of the following actions should
the nurse take?
• Apply zinc oxide ointment to the irritated area
• Wipe stool from the skin using store bought baby wipes
• Apply talcum powder to the irritated area
46.A nurse is caring for a client who has arteriovenous fistula. Which of the following findings should
the nurse report?
• Absence of bruit
• Patient with history of GERD
48.A home health nurse is preparing for an initial visit for an older adult who lives alone. Which
of the following actions should the nurse take first?
• Identify environmental hazards in the home
• (Unable to read)
• Tell the child they will feel discomfort during the catheter insertion.
• Use a mummy restraint to hold the child during the catheter insertion.
• Require the parents to leave the room during the procedure.
• Encourage a maximum fluid intake of 1,500 ml per day.
• Increase the amount of refined grains in the client’s diet.
• Provide the client with a cold drink prior to defecation.
• Administer a rectal suppository 30 minutes prior to scheduled defecation times.
51.A nurse is caring for a client who is in active labor and requests pain management. Which of the
following actions should the nurse take?
• Administer ondansetron.
• Place the client in a warm shower.
• Apply fundal pressure during contractions.
• Assist the client to a supine position.
5
• Below-the knee amputation
• Fractured tibia
• 95% full-thickness body burn
• 10cm (4in) laceration to the forearm
• Remove the client’s restraint every 4hr
• Document the client’s condition every 15 min
• Attach the restraint to the bed’s side rails
• Request a PRN restrain prescription for clients who are aggressive
54.A nurse is teaching an in-service about nursing leadership. Which of the following
information should the nurse include about an effective leader?
• Acts as an advocate for the nursing unit.
• (Unable to read) for the unit
• Priorities staff request over client needs.
• Provides routine client care and documentation.
55.A nurse is reviewing the laboratory findings of a client who has diabetes mellitus and reports that
she has been following her (unable to read) care. The nurse should identify which of the following
findings indicates a need to revise the client’s plan of care.
• Serum sodium 144 mEq/l
• (Unable to read)
• Hba1c 10 %
• Random serum glucose 190 mg/dl.
• Chlamydia
• Human papillomavirus
• Candidiasis
• Herps simplex virus
57.A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a
group on a mental health unit. Which of the following group facilitation techniques should the
nurse include in the teaching?
• Share personal opinions to help influence the group’s values
• Measure the accomplishments of the group against a previous group
• Yield in situations of conflicts to maintain group harmony
• Use modeling to help the clients improve their interpersonal skills
58.
• Provide chicken with cream sauce.
• Avoid serving fish with fins and scales.
• Provide unleavened bread.
• Avoid serving foods containing lamb.
• A chest x-ray reveals increased density in all fields.
• The client reports feeling less anxious.
• Diminished breath sounds are auscultated bilaterally
• ABG results include Ph 7.48 PaO2 77 mm Hg and PaCO2 47 mm Hg.
60
• “The proxy should make healthcare decisions for the client regardless of the client’s ability
to do so.”
• “The proxy can make financial decisions if the need arises.”
• “The proxy can make treatment decisions if the client is under anesthesia.”
• “The proxy should manage legal issues for the client.”
• Turn the client on their side.
• Administer an analgesic
• Administer antiemetic
• Monitor the client’s vital signs.
62
• Confirm the client’s perception of the event
• Notify the client’s support system
• Help the client identify personal strengths
• Teach the client relaxation techniques
• Request a renewal of the prescription every 8 hr.
• Check the client’s peripheral pulse rate every 30 min
• Obtain a prescription for restraint within 4 hr.
• Document the client’s condition every 15 minutes.
64.A charge nurse on a medical-surgical unit is planning assignments for a licensed practical
nurse (LPN) who has been sent from the postpartum unit due to a staffing shortage. Which of
the following clients should the nurse delegate to the LPN?
• A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs.
• A client who sustained a concussion and has unequal pupils.
• A client who is postoperative following a bowel resection with an NG tube set to continuous
suction.
• A client who fractured his femur yesterday and is experiencing shortness of breath.
• Place the client upright on a donut-shaped cushion
• Teach the client to shift his weight every 15 min while sitting
• Turn and reposition the client every 3 hr while in bed
• Assess pressure points every 24 hr
66.A nurse is caring for a client who is dilated to 10 cm and pushing. Which of the following painmanagement (Unable to read) a safe option for the client?
• Naloxone hydrochloride.
• Spinal anesthesia.
• Pudendal block.
• Butorphanol tartrate.
• The client changes the subject when future plans are mentioned.
• The client talks about being in pain constantly.
• The client is sleeping over 12 hr. each day.
• The client reports giving away personal items.
• Varicella vaccine.
• Inactivated polio vaccine.
• Tetanus diphtheria and acellular pertussis vaccine
• Rubella vaccine.
• Inactivated influenza vaccine.
6
• “I can give you information about respite care if you are interested.”
• “You should consider taking a sleeping pill before bed each night”
• “It must be difficult taking care of someone who is terminally ill”
• “You are doing a great job taking care of your mother”
70
• Methylprednisolone.
• Ondansetron.
• Guaifenesin.
• Amoxicillin.
71.The nurse is providing teaching about folic acid to a client who is primigravida. Which of the
following information should the nurse include in the teaching?
• “You should take folic acid to decrease the risk of transmitting infections to your baby”
• “You should consume a maximum of 300 micrograms of folic acid every day”.
• “You can increase your dietary intake of folic acid by eating cereals and citrus fruits”.
• “You can expect your urine to appear red-tingled while taking folic acid supplements”.
72.A community health nurse is assessing an adolescent who is pregnant. Which of the
following assessments is the nurse’s priority?
• Social relationship with peers.
• Plans for attending school while pregnant.
• Help adolescent to apply for Medicaid
• Understanding of infant care.
73.A nurse is reviewing the medical record of a client who has schizophrenia. Which of the
following should the nurse report to the provider?
Exhibit 1
Blood pressure: 102/56 mm Hg. Heart rate: 95/min
Respiratory rate: 18/min Temperature: 37.4C (99.3F)
Exhibit 2
Medication Administration Record
Clozapine 150 mg PO twice daily
Benztropine 0.5 mg PO twice daily as needed for tremors.
Exhibit 3
Nurse’s notes:
Client reports feeling dizzy when changing positions, Reports weight gain of 1kg (2.2 lb.) in the past
month. Also reports a sore throat for the past 3 days and dry mouth. Client ate 75% of breakfast and
reported feeling slightly nauseous.
• Dietary intake
• Heart rate.
• Sore throat. Yesssssss bitch
• Blood pressure.
• Contractions lasting 80 seconds
• FHR baseline 170/min
• Early decelerations in the FHR
• Temperature 37.4C (99.3)
• Consult with a case manager about insurance coverage.
• Counsel caregivers about respite care options.
• Ensure that the client has a referral for physical therapy.
• Refer the client to a local stroke support group.
• Encourage the client to spend time in the day room
• Withdraw the client’s TV privileges if the does not attend group therapy
• Encourage the client to take frequent rest periods
• Place the cline in seclusion when he exhibits signs of anxiety
77.A nurse is admitting medications to a group of clients. Which of the following occurrences
requires the completion of an incident report?
• A client receives his antibiotics 2hr late
• A client vomits within 20 min of taking his morning medications
• A client requests his statin to be administered at 2100
• A client asks for pain medication 1hr early
78.A nurse is caring for a client who is 24 hr. postpartum and is breastfeeding her newborns. The
client asks the nurse to warm up seaweed soup that the client’s partner brought for her. Which of
the following responses should the nurse make?
• “Does the doctor know you are eating that?”
• “Why are you eating seaweed soup?”
• “Of course I will heat that up for you”
• “The hospital food is more nutritious”
• Leaving a nasogastric tube clamped after administering oral medication
• Documenting communication with a provider in the progress notes of the client’s medical
records
• Administering potassium via IV bolus
• Placing a yellow bracelet on a client who is at risk for falls
80.A nurse is providing teaching to family members of a client who has dementia. Which of the
following instructions should the nurse include in the teaching?
• Establish a toileting schedule for the client
• Use clothing with buttons and zippers
• Discourage physical activity during the day
• Engage the client in activities that increase sensory stimulation
81.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?
• Hyperthyroidism.
• Thrombophlebitis.
• Diverticulosis.
• Hypocalcemia.
• “Do you understand that the voices are not real?”
• “Why do you think the voices are talking to you?”
• “Have you tried going to a private place when this occurs?”
• “What helps you ignore what you are hearing?”
• Placing a belt restraint on a school-age child who has seizures.
• Securing wrist restraints to the bed rails for an adolescent.
• Applying elbow immobilizers of an infant receiving cleft lip injury
• Keeping the side rails of a toddler’s crib elevated.
84.A nurse is preparing to mix NPH and regular insulin in the same syringe. Which of the
following
• Inject air into the NPH insulin vial.
• (Unable to read)
• Withdraw the prescribed dose of regular insulin
• Withdraw the prescribed dose of NPH insulin
• “Let’s talk about how you can change your response to stress.”
• “We should establish our roles in the initial session.”
• “Let me show you simple relaxation exercises to manage stress.”
• “We should discuss resources to implement in your daily life.”
• Waits 2 minutes between suctions.
• Encourages the client to cough during suctioning.
• Apply suctioning for 15 seconds.
• Inserts the catheter without applying suction.
87.A nurse is providing care for a group of clients. Which of the following client’s should the nurse
identify as having the highest risk for developing a pressure injury?
• A client who has a T-tube following an open cholecystectomy.
• A client who had a knee 2 days ago following a sports injury.
• A client who has dementia and is incontinent of urine and feces
• A client who has a myocardial infarction and is receiving thrombolytic therapy.
• “I will place the eye drops in the center of my eye”
• “I will place pressure on the corner of my eye after using the eye drops”
• “I should expect my tears to turn a red color after using the eye drops.”
• “I should expect the eye drops to appear cloudy.”
• “I would recommend sharing your feelings with a psychologist”.
• “I can give you information about making end of life decisions”.
• “You should discuss your end life decisions with your family”
• “Everyone feels this way at first. You will start feeling better soon”.
• Keep client’s calcium gluconate at the client’s bedside
• Monitor blood pressure every 2 hr. --- too long no?
• (Limit or remove?) IV bag from exposure to light. -(this medication should be protected from light)
• Attach an inline filter to the IV tubing.
91.A nurse is caring for a client who is experiencing mild anxiety. Which of the following
findings should the nurse expect?
• Feelings of dread
• Heightened perceptual field
• Rapid speech
• Purposeless activity
92.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?
• Withhold the next dose.
• Increase the dosage.
• Discontinue the medication.
• Administer the medication.
• Stay in bed at least 1hr if unable to fall asleep
• Take 1 hr nap during the day
• Perform exercise prior to bed
• Eat a light snack before bedtime
• Assess the amount of drainage in the collection chamber.
• Clamp the chest tube during ambulation.
• Report continuous bubbling in the water seal chamber.
• Strip the chest tube every 4 hr. to maintain patency.
• Productive cough.
• Urinary retention.
• Rhinitis
• Fever.
• “I will put my child on a gluten-free diet”.
• “I will administer digestive enzymes with meals and snacks”.
• “Provide my child with some high fiber foods.”
• “I will give my child whole wheat toast and milk for breakfast”.
• 0.9% normal saline.
• NPH insulin.
• Glargine insulin.
• 0.45% saline.
98.A nurse is teaching about preventative measures to a female client who has chronic urinary tract
infections. Which of the following interventions should the nurse include in the teaching?
● “Drink 2 liters of warm water per day”.
● “Empty your bladder every 6 weeks.”.
● “Soak in a warm bath everyday”.
● “Take an oral estrogen tablet”.
● A client who has sinus arrhythmia and is receiving monitoring
● A client who has a hip fracture and a new onset of tachypnea
● A client who has epidural analgesia and weakness in the lower extremities
● A client who has diabetes and a hemoglobin A1C of 6.8%
● Give the infant 30 ml (1 oz) glucose water every 2 hr.
● Keep the infant's head covered with a cap.
● Ensure that the newborn wears a diaper.
● Apply lotion to the newborn every 4 hr.
● “I should advise the client what I feel to be in his best health care decision”
● “I will intervene if there is conflict between a client and his provider”
● “I should not advocate for a client unless he is able to ask me himself”
● “I will inform a client that his family should help make his health care decisions.”
102. A nurse is preparing to reposition a client who had a stroke. Which of the following actions should
the nurse take?
● Raise the side rails on both sides of the client’s bed during repositioning.
● Reposition the client without assistive devices.
● Discuss the client’s preferences for determining a reposition schedule
● Evaluate the client’s ability to help with repositioning.
103. a nurse is auscultating for crackles on a client who has pneumonia. Which of the following anterior
chest wall locations should the nurse auscultate?
- - C
● A statement that participants can leave the study at will.
● An assignment of the participant to either the experimental or control group.
● A list of the clients participating in the study.
● A description of the framework the researchers will use to evaluate the data.
● Excessive sweating
● Increased urinary frequency
● Dry cough
● Metallic taste in mouth
106. A nurse is caring for a client who has a new temporary synchronous pacemaker. Which of the
following should the nurse report to the provider?
● The client’s pulse oximetry level is 96%.
● (Unable to read)
● The client develops hiccups.
● The ECG shows pacing spikes after the QRS complex
● Personal blogs about managing the adverse effects of diabetes medications
● Food label recommendations from the Institute of Medicine
● Diabetes medication information from the Physicians’ Desk Reference
● Food exchange lists for meal planning from the American Diabetes Association
● “The PCA will deliver a double dose of medication when you push the button twice.”
● “You can adjust the amount of pain medication you receive by pushing on the keypad.”
● “Continuous PCA infusion is designed to allow fluctuating plasma medication levels.”
● “You should push the button before physical activity to allow maximum pain control.”
● Administer a refrigerated feeding.
● Increase the amount of water used to flush the tubing.
● (Unable to read) rate of the client’s feedings.
● Instruct the client to move onto their right side.
● Provide information about stress management.
● Maintain a cool temperature in the client’s room.
● Administer epinephrine for acute episodes.
● Give glucocorticoid steroids twice per day
● Hyperlipidemia.
● COPD
● Seizure disorder
● Hyponatremia.
112. A nurse is caring for a client who is 12 hr. postpartum and has a third-degree perineal laceration.
The client reports not having a bowel movement for 4 days. Which of the following medications should
the nurse administer?
● Bisacodyl 10 mg rectal suppository.
● Magnesium hydroxide 30 ml PO.
○ Aka milk of magnesia
● Famotidine 20 mg PO.
● Loperamide 4 mg PO.
● Withhold all medications until after dialysis
● Rehydrate with dextrose 5% in water for orthostatic hypotension.
● Check the vascular access site for bleeding after dialysis.
● Give an antibiotic 30 min before dialysis.
● Develop a safety plan with the client
● Unable) options for reporting the incident.
● Refer the client to a community support group.
● Determine if the client has any injuries.
115. A nurse is assessing a school-age child who has a urinary tract infection. Which of the following
findings should the nurse expect?
● Periorbital edema.
● Decreased frequency of urination.
● Enuresis.
● Diarrhea.
116. A nurse is preparing to administer dopamine hydrochloride 4 mcg/kg/min via continuous infusion.
Available is dopamine hydrochloride in a solution of 800 mg in a 250 ml bag. The client weighs 80 kg.
The nurses should set the IV infusion to deliver how many mL/hr? (Round the answer to the nearest
whole number)
- __6__mL/hr
● “This test should be performed after your baby is 24 hours old.”
● “A nurse will draw blood from your baby’s inner elbow.”
● “Your baby will be given 2 ounces of water to drink prior to the test.”
● “This test will be repeated when your baby is 2 months old.”
118. A nurse is providing discharge teaching to a client who is postoperative following a colon
resection and has a new ascending colostomy. Which of the following statements by the client
indicates an understanding of the teaching?
● “My stool will become fully formed within 3 weeks”
● “My skin will need to be cleaned with alcohol before I apply a new pouch”
● “I should avoid eating popcorn and fresh pineapple”
● “I should expect bruising around the stoma”
● Refer the client to a speech language pathologist.
● Monitor the client’s prealbumin levels
● Measure the client’s weight.
● Place the client on NPO status.
● Providing written material for the client to read
● Plan a short instruction about coughing and deep breathing.
● Determine the client’s current pain level.
● Instruct the client about dietary restrictions.
● “I cannot be a witness for your consent to donate.”
● “Your name cannot be removed once you are listed on the organ donor list.”
● “Your desire to be an organ donor must be documented in writing.”
● “You must be at least 21 years of age to become an organ donor.”
● The client takes a hot bubble bath every day.
● The client wipes back to front when toileting.
● The client washes her perineum first when bathing.
● The client brushes her teeth twice daily.
● Dietitian
● Infection control nurse
● Nephrologist
● Cardiologist
● Emphasize important information using bold lettering.
● Use 7th grade reading level.
● Avoid using cartoons in the teaching material.
● Use words with three or four syllables.
• “Add salt to season”
● “Ice chips”
● “Rinse your mouth with an alcohol-based mouthwash”
● “Eat foods served at hot temperatures”
● Insert an indwelling urinary catheter.
● Apply a fetal heart rate monitor.
● Initiate fundal massage.
● Initiate an oxytocin IV infusion.
● Clarify the reason for the referral with the provider’s office.
● Contact the family to determine availability and readiness to make an appointment
● Identify family needs interventions using the nursing process.
● Discuss plans for future visits with the family.
● Record information about the home visit according to agency policy.
○ THIS IS THE CORRECT ORDER!
○ # 128 was deleted because it was the same question
○
1) -Sequence of visiting home health nurse a patient: - FROM NOTES
○ 1)get the referral from the hospital
○ 2)contact family schedule asap
○ 3)list interventions
○ 4)discuss future appointment
○ 5)charting
129. A nurse on a telemetry unit is assessing a client who is receiving continuous cardiac monitoring.
The client’s heart rate is 69/min and the PR interval is 0.24 seconds. The nurse should interpret this
finding as which of the following cardiac rhythms?
● First degree AV block
● Premature ventricular contraction.
● Sinus bradycardia.
● Atrial fibrillation.
● Ask the client directly what he is hearing
● Encourage the client to lie down in a quiet room
● Avoid eye contact with the client
● Refer to the hallucinations as if they are real
● “If there is a genetic risk for future pregnancies, we can get treatment now to prevent the disease”
● “There is no need to have genetic counseling if I know that I have a family history of mental illness.”
● My family has genetic risk for breast cancer, so I am considering a total mastectomy”
● “Even if I have a genetic risk for a disease the chance I will get the disease is probably low due to
current medical treatments.”
● “The cord stump will fall off in 5 days.”
● “Contact the provider if the cord stump turns black.”
● “Clean the base of the cord with hydrogen peroxide daily.”
● “Keep the cord stump dry until it falls off.”
● “I have my eyes examined annually”
● “I take a calcium vitamin supplement daily”
● “I limit my intake of foods with potassium”
○ Need more potassium
● “I constantly take my medication between 8 and 9 each evening”
● Peripheral edema
● Increased thirst.
● Flattened neck veins.
● Hypotension
136. A nurse is planning care for a client who has thrombocytopenia. Which of the following actions
should the nurse include?
● Encourage the client to floss daily.
● Remove fresh flowers from the client’s room.
● Provide the client with a stool softener.
● Avoid serving the client raw vegetables.
● Chest pain
● Muscle spasms.
● Cool, moist skin.
● Incisional pain
● Use NPH insulin to treat ketoacidosis.
● Administer NPH insulin 30 minutes before breakfast.
● Give NPH insulin by IV bolus
● Discard the NPH insulin vial if the medication is cloudy.
● Maintain the client’s oxygen saturation level at 89%.
● Place the client’s lower extremities on two pillows.
● Recommended that the client follow a 3g sodium diet.
● Place the client in a high fowler’s position.
● “You will need to monitor the client’s electrolytes daily”
● “You will need to change the IV dressing site once per week”
● “You will need to warm the solution in the microwave before administration”
● “You need to weigh the client twice per week”
● “I can visit my nephew who has chickenpox 5 days after the sores have crusted.”
● “I can clean my cat’s litter box during my pregnancy.”
● “I should take antibiotics when I have a virus.”
● “I should wash my hands for 10 seconds with hot after working in the garden.”
● “You should trust that your care team has your best interest at heart”
● “I will not share any personal information without your permission
● “The health care team will do their best to keep any promise we make to you”
● “We encourage you to participate in all decisions about your treatment”
● Takes assigned breaks at regular intervals
● Documents the clients care tasks at the end of the shift.
● assisting with ADLs to perform time sensitive activities
● Gather necessary supplies before beginning a dressing change.
- C
-
● Aspirin
● Magnesium sulfate
● Ginkgo biloba.
● Cetirizine
● Ibuprofen.
146. A nurse is calculating the body mass index (BMI) of a client who weighs 75 kg (165.3 lb) and is 1.8
m (5 ft 9 in) tall. The nurse should calculate the client’s BMI value as which of the following?
- 75/1.8/1.8 =23 …… formula = kg/m2
• 23
• 42
• 32
• 8
● The child expresses curiosity about the death process.
● The child refuses to talk about death.
● The child believes the person will return.
● The child focuses on his own mortality.
Exhibit 1
Laboratory Results Cerebrospinal fluid WBC 2,000/mm3 Neutrophils 88% Protein 320 mg/dl Glucose 35 mg/dl
Cloudy in appearance
Exhibit 2
History and Physical
Reports severe headache and photophobia. Disoriented to person, place, and time. Lethargic.
Exhibit 3
Vital Signs
BP 166/96 mm Hg
Respiratory rate 24/min
Pulse rate 112/min
Temperature 39.3C (102.8F)
Pain of 6 on a scale from 0 to 10
Glasgow score 9
● Place the client on a cooling blanket.
● Administer an analgesic.
● Obtain arterial blood gas levels.
BMI Categories:
Underweight = <18.5
Normal weight = 18.5–24.9
Overweight = 25–29.9
Obesity = BMI of 30 or greater
● Elevate the head of the client’s bed 30 degrees.
● Decreased hematocrit.
● Increased blood pressure.
● Tachycardia.
● Hypothermia.
● “Use a vein in the middle of the lower arm to insert a PICC.”
● “Flush a PICC using a 3-milliliter syringe.”
● “Informed consent is required prior to PICC placement.”
● “Position the client’s arm in adduction for PICC placement.”
● Furosemide 20 mg BID
● Nitroglycerin transdermal patch.
● Aspirin 1 tablet daily.
● Metoprolol 5 mg IV now.
● Restrict the client’s total fluid intake to 250 mL/hr
● Give the protamine if signs of magnesium sulfate toxicity occur
● Monitor the FHR via Doppler every 30 min
● Measure the client’s urine output every hour
153. A nurse is assessing a client who has acute kidney injury and a respiratory rate of 34/min. The
client’s ABG results are ph. 7.28 HCO3 18 mEq/L. PaCO2 (Unable to read) PaO2 90 mm Hg. Which of the
following conditions should the nurse expect?
● Metabolic acidosis.
● Metabolic alkalosis.
● Respiratory acidosis.
● Respiratory alkalosis.
● Zolpidem 10mg PO one tablet at bedtime
● Hydrochlorothiazide 12.5 mg PO BID
● Triamcinolone acetonide 100 mcg/inhalation two puffs TID
● Lorazepam .5mg PO one tablet daily
● Offer fluids every 2hr.
● Document the client’s behavior prior to being placed in seclusion.
● Discuss with the client his inappropriate behavior prior to seclusion 3'4$'#2/05'#2/('67#'&)7'8)'&)7'
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• Assess the client’s behavior once every hour.
156. A nurse in a provider’s office is preparing to administer the inactivated influenza vaccine. The
nurse should collect additional information for which of the following clients prior to administering the
vaccine?
● (Unable to read
● Client has (Unable to read) HIV/AIDS
● Client has a sensitivity to eggs.
● Client is experiencing seasonal allergies.
157. A nurse is reviewing the laboratory report of a client who has a prescription for digoxin. For which
of the following laboratory results should the nurse withhold the medication and notify the provider?
● Digoxin 0.8 ng/ml
● Sodium (Was out of range)
● BUN 15
● Potassium 3.1 mEq/L.
● “This type of seizure can be mistaken for daydreaming.”'3'./95$&:('+/%(#'($/;7%$'<
'' ' ' ' ' '
● “This type of seizure lasts 30 to 60 seconds.”
● “The child usually has an aura prior to onset.”
● “This type of seizure has a gradual onset.”
● Removal of vaginal packing
● Insertion of an indwelling urinary catheter
● Ambulation four times daily -- NO .. bedrest
● Maintenance of NPO status until therapy is complete
● aPTT.
● Pyro (Unsure if that’s the writing)
● Platelet count.
● INR.
● Identify solutions prior to negotiation
● Focus on how the conflict occurred
● Attempts to understand both sides of the issue
● Personalize the conflict
● Tachycardia.
● Narrowed pulse pressure.
● Hypotension.
● Increasingly severe headache.