ATI COMPREHENSIVE FINAL EXAM EXIT
1) A nurse in an emergency department completes an assessment on an adolescent client that has conduct
disorder. The client threatened suicide to teacher at school. Which of the following statements should the
nurse include in the assessment?
a) Tell me about your siblings
b) Tell me what kind of music you like
c) Tell me how often do you drink alcohol
d) Tell me about your school schedule
2) *A nurse is observing bonding to the client her newborn. Which of following actions by the client requires
the nurse to intervene?
a) Holding the newborn in an en face position
b) Asking the father to change the newborn's diaper
c) Requesting the nurse take the newborn nursery so she can rest
d) Viewing the newborn’s actions to be uncooperative
3) A nurse is caring for client who is taking levothyroxin. Which of the following findings should indicate that
the medication is effective?
a) Weight loss (this drug acts as T4 and will normalize the effects of hypothyroidism)
b) Decreased blood pressure
c) Absence of seizures
d) Decrease inflammation
4) A nurse is planning discharge teaching for cord care for the parent of a newborn. Which instructions would
you include in the teaching?
a) Contact provider if the cord still turns black (it’s going to turn black)
b) Clean the base of the cord with hydrogen peroxide daily (clean with neutral pH cleanser)
c) Keep the cord dry until it falls off (cord should be kept clean and dry to prevent infection)
d) The cord stump will fall off in five days (cord falls off in 10-14 days)
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5) A nurse is assessing a client in the PACU. Which of the following findings indicates decreased cardiac
output?
a) Shivering
b) Oliguria
c) Bradypnea
d) Constricted pupils
6) A nurse is assisting with mass casualty triage: explosion at a local factory. Which of the following client
should the nurse identify as the priority?
a) A client that has massive head trauma
b) A client has full thickness burns to face and trunk
c) A client with indications of hypovolemic shock
d) A client with open fracture of the lower extremity
7) A nurse is a receiving report on four clients. Which of the following clients should the nurse assess first?
a) A client who has illeal conduit and mucus in the pouch
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b) Client pleasant arteriovenous additional vibration palpated
c) A client whose chronic kidney disease with cloudy diasylate outflow
d) A client was transurethral resection of the prostate with a red tinged urine in the bag
8) A nurse is caring for a client just received the first dose of lisinopril. The following is an appropriate nursing
intervention?
a) Place’s cardiac monitoring
b) Monitor the clients oxygen saturation level
c) Provide standby assist with the client from bed
d) Encourage foods high in potassium
9) A nurse is caring for a client who is in labor and his seat is receiving electronic fetal monitoring. The
nurse is reviewing the monitor tracing and notes early decelerations. Which the following should the nurse
expect?
a) Feta hypoxia
b) Abrupto placentae
c) Post maturity
d) Head Compression
10) A nurse is caring for a client who has chronic kidney disease. The nurse should identify which of the
following laboratory values as in an indication for hemodialysis?
a) glomerular filtration rate of 14 mL/ minute
b) BUN 16 mg/DL
c) serum magnesium 1.8 mg mg/dl
d) Serum phosphorus 4.0 mg/dL
11) A nurse is caring for an infant who has a prescription for continuous pulse oximetry. The following is an
appropriate action for the nurse to take?
a) Placed infant under radiant warmer
b) Move the probe site every 3 hours
c) Heat the skin one minute prior to placing the program
d) Placed a sensor on the index finger
12) A nurse in a mental health facility receives a change of shift report on for clients. Which of the following
clients should the nurse plan to assess first?
a) Client placed in restraints to the aggressive behavior
b) A new limited client pleasures history of 4.5 kg weight loss in the past two months
c) Client is receiving a PRN dose of health heard all two hours ago for increased anxiety
d) Applied he’ll be receiving his first ECT treatment today
13) A nurse working at the clinic is teaching a group of clients who are pregnant on the use of
nonpharmacological pain management. Which of the following statements by the nurse is an appropriate
description of the use of hypnosis during labor?
a) Hypnosis focuses on the biofeedback as a relaxation technique
b) Hypnosis promotes increased control of her pain perception during contractions
c) Hypnosis uses therapeutic touch to reduce anxiety during labor
d) Hypnosis provides instruction to minimize pain
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14) A nurse in a County Jail health clinic is leading group therapy session. A client who was incarcerated for
theft is addressing the group. Which of the following is an example of reaction formation? (rxn formation
is when you use opposite feelings; ex: being super nice to someone you dislike)
a) I steal things because it’s the only way I can keep my mind off my bad marriage
b) I can’t believe I was accused of something I didn’t do
c) I don’t want talk about my feelings right now. We will talk more next time
d) I think that people just you’re just lazy and should earn money honestly
15) A nurse is obtaining the medical history of a client who has a new prescription for isosorbide monotitrate.
Which of the following should the nurse identify as a contraindication to medication?
a) Glaucoma
b) Hypertension
c) Polycythemia
d) Migraine headaches
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17) The nurses is caring for a client recovering from an acute myocardial infarction. Which following
intervention should the nurse include in the point of care?
a) Draw a troponin level every four hours
b) Performance EKG every 12 hours
c) Plant oxygen tent fell over minutes via rebreather mask
d) Obtain a cardiac rehabilitation consult
18) A Nurses caring for client who has breast cancer and has been covering receiving chemotherapy. Which of
the following laboratory values should nurse report to provider?
a) WBC 3,000/mm3
b) Hemoglobin 14 g/dl
c) Platelet 250,000/mm3
d) aPTT 30 seconds
19) Home health nurse is carefully planned for Alzheimer’s disease. To the following action should the nurse
include in the plan of care
a) Place a daily calendar in the kitchen
b) Replace button clothing with zippered items
c) Replace the carpet with hardwood floors
d) Create variation in daily routine
20) Nurse is performing change of shift assessments on 4 clients. Which of the following findings should the
nurse report to provider first?
a) The client was cystic fibrosis and has a thick productive clock and reports thirst
b) Client who has gastroenteritis and is lethargic and confused
c) The Client has diabetes mellitus has morning fasting Legal cost of 185 mg over deal
d) The client was sick of signing it reports pain 15 minutes after receiving oral analgesic
21) A nurse is caring for a client was in the second trimester of pregnancy and asks how to treat constipation.
Which of the following statements by the nurse is appropriate?
a) Decrease taking vitamins and supplements to every other day
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b) Eat 15 g of fiber per day
c) Consume 48 ounces of water each day (need at least 64 oz)
d) Drink hot water with lemon juice each morning when you wake up
23) A nurse is caring for a client who is preparing his advance directives. Which is the following statements by
the client indicates an understanding of advanced directives? select all that apply
a) I can’t change my instructions once a minute
b) My doctor will need to approve my advance directives
c) I need an attorney to witness my signature on the advance directives
d) I have the right to refuse treatment
e) My health care proxy can make medical decisions for me
24) A nurse is caring for a client who is at 32 weeks gestation and has a history of cardiac disease. Which of
the following positions should the nurse place the client to best promote optimal cardiac output?
a) The chest
b) Standing
c) Supine
d) Left lateral
25) A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an AP?
a) Client who has chronic obstructive pulmonary disease and needs guidance on incentive spirometry
b) Client who has awoken following a bronchoscopy and requests a drink
c) Client who had a myocardial infarction 3 days ago reports chest discomfort
d) Client who had a cerebrovascular accident two days ago and needs help toileting
26) Nurse providing discharge teaching to the client who has schizophrenia and is starting therapy with
clozapine. Which of the following is the highest priority for the client to report to the provider?
a) Constipation
b) blurred vision
c) Fever
d) Dry Mouth
27) A nurse observes an AP providing care to a child who is in skeletal traction. Which of the following action
requires intervention?
a) Providing a high protein snack
b) Assisting the child to reposition
c) Placing weights as a child’s bed
d) Massaging pressure points-causes skin breakdown
28) A nurse is planning to delegate to an AP the fasting blood glucose testing for a client who has diabetes
mellitus. Which of the following action should the nurse take?
a) Determine if the AP is qualified to perform the test.
b) Help the AP performed the blood glucose test
c) Assign the AP to ask the client is taking his diabetic medication today
d) Have AP check the medical record for prior blood glucose test results
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29) A nurse is assessing client brought to the hospital psychiatric emergency services by a law enforcement
officer. The client has disorganized, incoherent speech with loose associations and religious content.
You should recognize the signs and symptoms as being consistent with which of the following?
a) Alzheimer’s disease
b) Schizophrenia
c) Substance intoxication
d) Depression
30) A nurse is caring for a child who has infectious mononucleosis.. Which of the following findings are
associated with this diagnosis? Select all that apply
a) splenomegaly
b) Koplik spots (this is associated with measles)
c) Malaise
d) Vertigo
e) Sore throat
31) Nurse is performing dressing change for client was a sacral wound using negative pressure wound
therapy. Which The following actions should the nurse take first?
a) Apply skin preparation to wound edges.
b) Normal saline
c) Don sterile gloves
d) Determine pain level
32) A nurses caring for client recovery from the bowel surgery who has nasogastric tube connected to
low intermittent suction. Which the following assessment findings should indicate to the nurse that the NG
tube may not be functioning properly?
a) Drainage fluid is greenish-yellow
b) aspirate pH of 3
c) Abdominal rigidity
d) air bubbles noted in the NG tube
33) A nurse is preparing to administer TPN with added fat supplements to a client who has malnutrition.
Which of the following action should the nurse take?
a) Piggyback 0.9 sodium chloride with TPN solution
b) Check for an allergy to eggs
c) Discuss the TPS solution for 12 hours
d) Monitor for hypoglycemia
34) A charge nurse is discussing the use of applying ice to a client’s injured knee with a newly licensed nurse.
Which of the following should the nurse identify as a benefit? (A/C?)
a) Systemic analgesic effect
b) increase in your metabolism
c) Decreased capillary permeability
d) Vasodilation
35) Nurse is developing discharge care plans for client has osteoporosis. To prevent injury the nurse should
instruct the client to
a) Perform weight bearing exercises
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b) Avoid crossing the legs beyond the midline
c) Avoid sitting in one position for prolonged periods
d) Split affected area
36) A nurse on acute med-surgical unit is performing assessments on a group of clients. Which is highest
priority?
a) The client has surgical hypoparathyroidism and positive Trousseau’s sign
b) A client who was Clostridium difficile with acute diarrhea
c) A client who is acute kidney injury and urine with a low specific gravity
d) The client who has oral cancer and reports a sore on his gums
37) Nurses caring for a client was congestive heart failure. Which of the following prescriptions for the
provider should the nurse anticipate?
a) Call the provider to clients respiratory rate is less 18/min
b) Give the client 500 mL IV bolus of 0.9 sodium chloride over 1 hr
c) Give the client enalapril 2.5 mg PO twice daily
d) Call the provider if the clients pulse rate is less than 80/min
38) A nurse is caring for a client who has a prescription for sertraline to treat depression. Which of the
following statements by the client indicates an understanding of the medication treatment plan?
a) I will be able starting this medication with feel better
b) I can expect to urinate frequently while on this medication
c) I understand I may experience difficulty sleeping on this medication
d) I should decrease my sodium intake while on this medication
39) A nurse has been caring for a female client who has bruises on her arms that she explains are a result of
physical abuse by her husband. The client states, “I don’t know how much longer I can take this, but I’m
afraid he’ll really hurt me if I leave. “Which of the following is an appropriate nursing intervention?”
a) Offer to speak to the client’s husband regarding his abuse behavior.
b) Help the client to recognize the signs of escalation of abuse behavior
c) Assist the client to identify personal behaviors that trigger abusive behavior
d) Assist the client to Reports abusive behavior to the proper authority
40) A client was having suicidal thoughts tells the nurse “It just does not seem worth it anymore. Why not end
my misery?” Which of the following responses for the nurses appropriate?
a) Why do you think your life is not worth it anymore?
b) Do you have a plan to end your life?
c) I need to know what you mean my misery
d) You can trust me and tell me what you’re thinking
41) A nurse is caring for a client who has schizophrenia. Which of the following assessment findings should
the nurse expect?
a) Decreased level consciousness
b) Unable to identify common objects
c) Poor problem solving ability
d) Preoccupation was somatic disturbances
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42) A nurse is caring for a client who has deep vein thrombosis of the left lower extremity. Which of the
following action should nurse take? There are 3 tabs that contain separate categories of data.
a) Position the client with the affected extremity lower than the heart
b) Administration of acetaminophen
c) Massage the affected extremity every 4 hrs.
d) Withhold heparin IV infusion
43) Is caring for clients was a new prescription for enoxaparin for the prevention of DVT. Which of the
following is an appropriate action by the nurse?
a) Expel air bubble at the top of the prefilled syringe
b) Massage the injection site to evenly distribute the medication
c) Inject the medication the lateral abdominal wall
d) Administer an NSAID for injection site discomfort
44) Nurses caring for four clients. Which of the following client data should the nurse report to the provider?
a) A client who has a pleurisy and reports pain of 6 on a scale of 0 to 10 when coughing
b) Client was a total of 110 mL of serosanguineous fluid from the Jackson Pratt drain within the first 24
hour following surgery
c) Client who is 4 hrs postoperative and has a heart rate of 98 per minute
d) The client was a prescription for chemotherapy and an absolute neutrophil count of 75/mm3
45) Nurses caring for client was in end-stage osteoporosis and is reporting severe pain. Clients respiratory
rate is 14 per minute. Which of the following medications should the nurse expect to be the highest
priority to administer to the client?
a) Promethazine
b) Hydromorphone
c) Ketorolac
d) Amitriptyline
46) A nurse is caring for a client who has DVT. Which of the following instructions the nurse include in the
plan of care?
a) Live with the clients fluid intake to 1500 mL per day
b) Massage place affected extremity to relieve pain
c) Apply cold packs of clients affected extremity
d) Elevate the client’s affected extremity when in bed
47) A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client’s
contractions are occurring every 45 seconds with a nine seconds duration in the fetal heart rate is 170 to
180/minute. Which of the following actions should nurse take?
a) Discontinue oxytocin infusion
b) Increased oxytocin infusion
c) Decreased oxytocin infusion
d) Maintain oxytocin infusion
48) A nurse is admitting a client who is in labor and at 38 wks of gestation to the maternal newborn
unit. The client has a history of herpes simplex virus 2. Which of the following questions is most
appropriate for the nurse to ask the client?
a) Have your membranes ruptured?
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b) How far apart are your contractions?
c) Do you have any active lesions?
d) Are you positive for beta strap?
49) Nurse is providing teaching for child prescribed ferrous sulfate. Which of the following instructions should
the nurse include?
a) Take with meals
b) Take at bedtime
c) Take with a glass of milk
d) Take with a glass of orange juice
50) Four clients present to the emergency department. The nurse should plan to see which of the following
clients first?
a) A 6 year old client whose left shoulder is dislocated
b) A 26 year old client for sickle cell disease and a severe joint pain
c) A 76 year old client was confused, febrile and has foul smelling urine - uti
d) A 50- year old client who has slurred speech, is disoriented, and reports a headache - stroke
51) A nurse is completing a dietary assessment for client who is Jewish and observes kosher dietary practices.
Which of the following behaviors should the nurse expect to find?
a) Leavened bread maybe eaten during Passover.
b) Shellfish is commonly consumed in the diet.
c) Meat and dairy products are eaten separately.
d) Fasting from meat occurs during Hanukkah.
52) ?
53) A nurse is in an ER caring for client of multiple wounds due to a motor vehicle crash. Which of the
following interventions are appropriate? Select all that apply
a) Apply direct pressure to bleeding wounds
b) Clean rest last rations and abrasions with hydrogen peroxide
c) Cover wounds with a sterile dressing
d) Administer 650 mg aspirin PO as needed for pain
e) Determine date of last tetanus toxoid vaccination.
54) The nurses reviewing clients admission laboratory results. Which of the findings required further
evaluation?
a) Sodium 138
b) Creatinine 1.8
c) Hemoglobin 15
d) Potassium 4.2
55) A nurse is providing teaching for a client has a new prescription for methadone. Which of the phone
following client statements indicates need for further teaching?
a) I understand the methadone tends to slow my breathing
b) I understand the methadone may cause me to have difficulty sleeping
c) I will avoid alcohol while I’m taking this medication
d) I’ll change positions gradually especially from lying down to standing
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56) Which of the following client is appropriate for the nurse to refer to speech therapy for swallowing
evaluation?
a) Premature infant with a poor suck reflex and failure to thrive
b) An older adults who has difficulty taking in fluids
c) Adolescent who anorexia who is cachectic
d) A middle aged adults was gastroesophageal reflux disease
57) A nurse is caring for a group of clients. Which of the following client should nurse assess first?
a) A client whose benign prostatic hyperplasia and is unable to urinate
b) The client was heart failure and report shortness of breath while ambulating
c) A client who is open cholecystectomy and has green drainage from the T-tube
d) A client whose abdominal pain and is vomiting coffee ground emesis
58) A nurse is taking a medication history from client was type II diabetes mellitus is scheduled for an
arteriogram. Which of the following medications to the nurses instruct the client to discontinue 48 hrs
prior to the procedure?
a) Atorvastatin
b) Digoxin
c) Nifedipine
d) Metformin
59) The nurses assessing client with posttraumatic stress disorder. Which of the following findings to the
nurse expect to find?
a) Dependence on family and friends
b) Loss of interest in usual activities
c) Ritualistic behavior
d) Passive aggressive behavior
60) A nurse working in a long-term care facility is caring for an older adult client has dementia. The clients
often agitated and frequently wanders the halls. Which of the following intervention should the nurse
include in the plan of care?
a) Give the client several choices when scheduling activities.
b) Confront the client regarding unacceptable behavior
c) Maintain Nutritional requirements by offering finger foods
d) Stimulate the client by leaving the television on throughout the day
61) A nurse on a mental health unit receives report on four clients. Which of the following client should the
nurse attend to first?
a) A client who has begun to demonstrate catatonic behavior
b) The client was compulsive behavior and is frequently drinking from the water fountain
c) Client was having auditory hallucinations is becoming agitated
d) A client was making sexual comments to clients of the opposite sex
62) A nurse is caring for the full term newborn immediately following birth. Which of the following actions
should the nurse take first?
a) Instill erythromycin ophthalmic ointment and the newborn’s eyes.
b) Place identification bracelets on the newborn.
c) Weigh the newborn.
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d) Dry the newborn
63) A nurse receives report on a group of clients. Which of the following client should the nurse attend to first?
a) A client who was admitted with asthma and has an SaO2 of 92% long receiving oxygen at 1 L per
minute via nasal cannula
b) A client was admitted with angina and reports left arm pain of 4 on a scale of 0 to 10
c) The client was type II diabetes mellitus in his blood with glucose level is at 80 mg/dL
d) A client who had a gastric endoscopy and whose nasogastric tube is draining 30 mL per hour of green
fluid
64) A client at 38 weeks of gestation enters the emergency department. The nurse should recognize that which
of the following indicates that the client is in the latent phase of labor?
a) The client reports the urge to push
b) The cervix is dilated 2 cm
c) Contractions are 2 to 3 minutes apart
d) The client reports nausea and vomiting
65) The charge nurse for medical surgical units discovers client care assignments that should be reassigned.
Which of the following delegated tasks should be reassigned?
a) An AP is to calculate intake and output every two hours for client in acute renal failure.
b) An AP is to collect vital signs every 30 minutes for client who had a cholecystectomy
c) A licensed practical nurse is to check nasogastric tube placement for client list had a bowel resection.
d) A licensed practical nurses to provide initial feeding for client who had a cerebrovascular accident.
66) A nurse caring for the client who has a cast due to a compound fracture to the right ankle. Which of the
following findings requires immediate intervention?
a) pruiritus under the cast
b) Localized stabbing pain upon movement
c) paresthesia of the distal extremity
d) Edema present when leg is in the dependent position
67) The nurses providing care for preschoolers with acute gastroenteritis. Basing information below which of
the following is an appropriate nursing action? Click on the links of this below for additional client
information
a) Offer the child a cup of chicken broth.
b) Encourage the child’s intake of gelatin.
c) Administer oral rehydration solutions.
d) Institute a banana, Rice, applesauce, and toast diet.
68) The nurses caring for a client whose taking allopurinol. The nurse should monitor which of the following
laboratory findings to determine the effectiveness of the medication?
a) Serum chloride
b) Uric acid level
c) Serum albumin
d) Magnesium level
69) A nurse is caring for a client on the cardiac care unit who is hemodynamically unstable. Which of the
following dysrhythmias should the nurse plan for cardioversion?
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a) Ventricular asystole
b) Third-degree AV block
c) Atrial fibrillation
d) Ventricular fibrillation
70) Nurse managers preparing an educational program on infection control measures. Which of the following
should the nurse include when discussing contact precautions?
a) Scarlet fever
b) Herpes simplex
c) Varicella
d) Streptococcal pharyngitis
71) A nurse assesses an older adult client with the decrease caloric intake and weight loss. Which of the
following findings should the nurse report to the provider immediately?
a) The clinic experiences coughing and wheezing after eating.
b) The client reports abdominal pain at a five on a scale of 0 to 10.
c) The client experience is a drop in oxygen saturation to 91% while eating.
d) The client reports a burning sensation in epigastric area.
72) A nurse and an assistive personnel are caring for a group of clients. Which of the following tasks is
appropriate for the nurse to delegate an AP?
a) Applying condom catheter for client for spinal cord injury
b) Administrative oral fluids to client was dysphasia
c) Documenting the report of pain from client who is postoperative
d) Reviewing active range of motion exercises with a client who is had a stroke
73) A nurse from the state health department this is instructing a group nurses regarding reportable infections.
Which of the following infections should the nurse report to the CDC?
a) Candida albicans
b) Herpes simplex virus 2
c) staphylococcus aureus
d) Lyme disease
74) The nurse is assessing an adolescent client for sickle cell anemia. Which of the following is a priority
finding by the nurse?
a) A pain score 7 on a scale of 0 to 10
b) Shortness of breath
c) New onset of a new enuresis
d) Priapism
75) Nurses caring for a client whose 1 day postop following a Hypophysectomy for the removal of the
pituitary tumor. Which of the following findings requires further assessment by nurse?
a) Glascow scale score a 15
b) Blood drainage on initial dressing measuring 3 cm
c) Report of dry mouth
d) Urinary output greater than fluid intake
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76) A client with the left leg cast is using crutches for ambulation. The nurse recognizes client needs further
instruction of the client
a) Flexes elbows at 30 degrees when using the handgrips
b) Maintains 3 to 4 finger width between the crutch pad and axilla
c) Places the crutches 6 inches in front and side of each foot when standing.
d) Pushes up from a chair with crutches on the unaffected side.
77) A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions
should the nurse plan to take?
a) Use a designated stethoscope when caring for the toddler.
b) Wear an N95 respiratory mask while caring for the toddler.
c) Remove the disposable gown after leaving the toddler’s room
d) Place the toddler in a room with negative air pressure.
78) A nurse is admitting to a client to emergency department and initiates continuous cardiac
monitoring. Which of the following ECG with strips indicates sinus tachycardia?
b)
79) A nurse is planning care for client to prevent complications of immobility. With the following
actions should the nurse including the plan of care?
a) Massage lower extremities daily to prevent DVT
b) Limit intake of Food high in calcium to prevent renal calculi.
c) Encourage client to lie supine prevent constipation.
d) Remove anti embolism stockings for 3 hours each day to decreased skin breakdown.
80) A nurse discovers that the wrong dosage of medication was given to client. When determining
what action to take your should recognize that which of the following ethical principles should be applied?
a) Utility
b) Paternalism
c) Veracity
d) Fidelity
81) ?
82) A nurse is review in the prescription for doxazosin with a client. Which of the following should be
included in the teaching?
a) Decrease caloric intake to reduce weight gain.
b) Increased dietary fiber to prevent constipation.
c) Rise slowly when sitting up from bed.
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d) Take this medication each morning.
83) Addresses planning to provide teaching to young adult client who is insomnia. Which of the
following should the nurse include in the teaching?
a) Exercising an hour before bedtime
b) Take a short nap today
c) Keep bedroom cool at night
d) Consume a high carbohydrate snack at bedtime.
84) A nurse is caring for client who has a stool culture that is positive for Clostridium difficile. Which
of the following infection control precautions is appropriate?
a) Wear a face shield prior into entering the room.
b) Place the client private room.
c) Place the client in a negative pressure room.
d) Use alcohol based hand rub following client care.
85) A nurse is planning care for a child who has increased intracranial pressure with a decreased
level of consciousness. Which of the following intervention should the nurse including the plan of care?
a) Perform active range of motion exercises.
b) Perform neurological checks every 4 hours.
c) Suction the airway frequently.
d) Maintain the head at a midline position.
86) The nurse is assessing a client is receiving radiation therapy. Which of the following findings
should the nurse expect?
a) White blood cell count at 12,500 mm3
b) Excessive salivation
c) +3 pitting edema
d) Platelets 95,000 mm3
87) A nurse is caring for a client who has preeclampsia and is experiencing postpartum hemorrhage.
The nurse should identify that which of the following medications is contraindicated?
a) Methylergonovine.
b) Misoprostol
c) Dinoprostone
d) Oxytocin
88) A nurse is caring for client was GERD. Which of the following assessment findings the nurse expect
to find?
a) Shortness of breath
b) Rebound tenderness
c) Atypical chest pain
d) Vomiting blood
89) A nurse is caring for a newborn who is under phototherapy lights. Which of the following is an
appropriate nursing action?
a) Ensure eye shield is covering the eyes.
b) Apply lotion to expose skin.
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c) Offer glucose water between feedings.
d) Discontinue breast-feeding during treatment.
90) This is assessing clients as had a long arm cast. Which of the following findings of the dress
moderate and when assessing for acute compartment syndrome?
a) Shortness of breath
b) Petechiae
c) Change in mental status
d) Edema
91) I Just came from client is receiving IV moderate (Conscious) sedation with midazolam. The client
has a respiratory rate of 9/min and is not responding to commands. Which of the following is an appropriate
action by the nurse?
a) Placed the client in a prone proposition.
b) Implement Positive pressure ventilation.
c) Perform nasopharyngeal suctioning.
d) administer flumazenil
92) A nurses in a hospital cafeteria overhears two assistive personnel (AP) discussing a client. They are
using the clients name and discussing details of his diagnosis. Which of following actions should the nurse
take first?
a) Report the AP’s behavior to the supervisor.
b) Completed instant report regarding the Aps conversation.
c) Provide the AP with written documentation regarding client confidentiality
d) Tell the AP to discontinue their conversation
93) A community health nurse is teaching a group of adults about the importance of health screenings.
The nurse should include African American males almost twice as likely as caucasian males to
experience which of the following?
a) testicular Cancer
b) Obesity
c) Stroke
d) Melanoma
94) A nurse is caring for a client who sprained his left ankle 12 hrs ago . Which of the following
prescription is given by the provider should the nurse clarify?
a) Over the fact that extremities and two pillows.
b) Apply heat to affect extremity for 45 minutes on the 45 is off.
c) wrap the affected extremity with a compression dressing.
d) Assess the affected extremity for sensation movement impulse every four hours
95) A nurse is providing dietary teachings for client who has hepatic encephalopathy. Which the
following food selections indicates that client understands teaching?
a) A sandwich and milkshake
b) Rice with black beans
c) Cottage cheese and tuna lettuce
d) Three egg omelette with low-sodium ham
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96) A nurse is planning care for client sealed radiation implant and is to remain in the hospital for 1
week. Which of the following should the nurse include in the plan of care?
a) Remove dirty linens from the room after double bagging.
b) Wear a dosimeter film badge while in the client’s room
c) Limit each of the clients is yours to one hour per day.
d) Ensure family members remain at least 3 feet from the client.
97) A nurses for Caring for four clients. Which of the following client should the nurse care for first?
a) A client to receive a chemotherapy treatment or first national
b) A client who has an appendectomy to these don’t has diminished all sounds
c) A client is hypothyroidism and his stuporous
d) A client who is a burn requiring a sterile dressing change
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98) The nurses planning care for newly admitted adolescent who has bacterial meningitis. Which the
following instructions is appropriate for the nurse to include in the plan of care?
a) Initiate droplet precautions for the client
b) Assisted client to supine position
c) Performing Glasgow coma scale every 24 hrs
d) Recommend prophylactic acyclovir there for the clients family.
99) Nurse is giving discharge instructions to client has new ileostomy. The nurse should recognize that
the teaching has been effective when the client states.
a) I want sure that my medications are enteric coated
b) My stoma will drain liquid fluid continuously
c) I will change my pump system every two weeks
d) My stoma size will stay the same even after healed
100) A nurse in a provider’s office is interviewing a client who is requesting an oral contraceptive. Which
of the following findings in the client’s history is a contraindication to use in combination oral
contraceptives?
a) thyroid disease
b) Allergy to penicillin
c) impaired liver function
d) abnormal blood glucose
101) The nurses providing teaching to a client who has mild persistent asthma has been prescribed
montelukast. Which of the following statements to the nursing put in teaching?
a) This medication can be used to help you when have an acute asthma attack
b) This medication should be taken before exercise and physical activity
c) This medication can be taken for 10 days and then gradually discontinued
d) This medication helps decrease swelling and mucus production
102) I nurse on the medical surgical unit is receiving reports on four clients. Which of the following
client should the nurse assess first?
a) A client who is receiving warfarin and has and INR of 3.3
b) A client who has an acute kidney injury, a creatinine of 4 mg/dL, and a BUN 52 mg/dL
c) A client who had a NG tube inserted 6 hr ago and has abdominal distention
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d) A client who is 4 hr postoperative following a thyroidectomy and reports fullness in the back of the
throat
103) A nurse is assessing a client who has pericarditis. Which of the following findings is priority
a) Paradoxical pulse pg. 389 under complications
b) dependent edema
c) Pericardial friction rub
d) Substernal chest pain
104) A charge nurse is providing teaching to a new licensed nurse on how to cleanup surfaces
contaminated with blood. Which of the following agents said the nurse include in the teaching?
a) Hydrogen peroxide
b) Chlorhexidine
c) Isopropyl alcohol
d) Chlorine bleach
105) *A nurse is preparing to feed a newly admitted patient with dysphagia. Which of the following
actions in response take?
a) instruct the client to lift her chin when swallowing
b) discourage the client from coughing during feedings
c) Sit at or below the clients eye level during feedings.
d) Talk with the client during her feeding.
106) A nurses caring for a client who repeatedly refuses meals. The nurse overhears an assistive
personnel telling the client. “If you don't eat, I’ll put restraints on your wrists and feed you.” The nurse
should intervene and explain to the AP that this statement constitutes which of the following torts?
a) Assault
b) Battery
c) Malpractice
d) Negligence
107) A charge nurse is evaluating the time management skills for new licensed nurse. The charge nurse
should intervene when a newly licensed nurse does which of the following?
a) Re-Evaluate priorities halfway through the shift
b) Delegate changing sterile dressing for licensed practical nurse
c) Groups activities for the Same client
d) Works on several tasks simultaneously
108) A nurse is monitoring the client during an IV urography procedure. Which of the following client
reports is the priority finding?
a) Feeling flushed and warm
b) Abdominal fullness
c) Swollen lips
d) Metallic taste in mouth
109) A nurse is planning to delegate client assignments to the assistive personnel. which of the following
task is appropriate for the nurse to delegate?
a) Just the flow rate of the clients oxygen tank
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b) Collecting urine sample
c) Measuring the clients pain level
d) Monitoring blood glucose levels
110) A nurse is assessing a client wasn’t following vital signs: Oral temperature of 37.2°C (99 F). Apical
pulse rate of 80/min, radial pulse rate 62/min, respiratory rate of 16/min, and blood pressure of 132/40 mm
Hg. What is the clients pulse pressure?
a) Systolic presssure subtracted by diastolic pressure (132 - 40) = 92
111) A nurse if caring for a group of clients in a medical surgical unit. Which of the following situations
requires completion of an incident report?
a) A client who is absent gag reflex following a bronchoscopy
b) A client whose IV pump has malfunctioned
c) A client who requires insertion of NG tube due to a bowel obstruction
d) A client who is absent bell sounds following a gastrectomy
112) A nurse is caring for a client who has diabetes insipidus and is receiving desmopressin. Which of
the following should nurse monitor?
a) Fasting blood glucose
b) Carbohydrate intake
c) Hematocrit
d) Weight
113) The nurses providing discharge instructions about engorgement for client has decided not to
breastfeed. Which of the following statements by the client indicates a need for further instruction by the
nurse?
a) I can wear support bra
b) I will play cold compression my breasts
c) I will manually express breastmilk
d) I can take a mild analgesic
114) A nurses caring for client in preterm labor who is receiving magnesium sulfate by continuous IV
infusion. Which of the following client findings indicates medication toxicity?
a) Blood glucose of 150 mg/dL
b) Urine output of 20 mL per hour
c) Systolic blood pressure at 140 mm Hg
d) BUN 20 mg/dL
115) The nurse is completing an assessment for newborn who is 2 hrs old. Which of the following
findings are indicative of cold stress?
a) Respiratory rate of 60 per minute
b) Jitteriness of the hands
c) Diaphoretic
d) Bounding peripheral pulses in all extremities
116. A nurse is planning care for four clients. Which of the following clients is the highest priority?
a. A client who is dry, black eschar on the heel
b. A client who is wearing an arm cast and reports numb fingers
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c. The client was reddened skin area with blanching around the coccyx
d. The client who has frequent incontinence
117. A nurse is caring for a male adolescent client who has heart failure. Based on the client’s chart
finds. Which of the following actions should the nurse plan to take?
a. Withholds spiranolactone
b. Administer ferrous sulfate
c. Administer furosemide
d. Withhold digoxin (0.8-2.0)
118. The nurses assessing a client plus blood glucose level of 250 mg/dl. Which of the following clinical
manifestations are associated with this finding?
a. Confusion (hypoglycemia)
b. Thirst
c. Diaphoresis (hypoglycemia)
d. Shakiness (hypoglycemia)
119. A nurse is assessing for allergies before administering Propofol to a client placed on the mechanical
ventilator. Which of the following allergies is a contraindication to the medication?
a. Eggs
b. Milk
c. Shrimp
d. Peanuts
120. A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client to interpret the
following statement, “When the cat’s away, the mice will play”. The client response was, “The mice
come out when the cat is not around”. The nurse should document this finding which of the following in
the client’s chart?
a. Echolalia
b. Associative looseness
c. Neologisms
d. Concrete thinking
121. A nurse caring for a client who is receiving total parental nutrition. Which of the following
assessment findings required immediate intervention by the nurse?
a. prealbumin level of 20 mg/dL
b. Weight increase of two kg/day
c. Temperature of 37.6°C
d. Blood glucose level of 120 mg/dL
122. A nurse in the telemetry unit is receiving the laboratory findings for adult male client who’s been
treated for myocardial function. The following is an expected finding for the client?
a. Troponin 1 (TNI) 8 ng/ml
b. Brain natriuretic peptide (BNP) 10 ng/L
c. Alanine aminotransferase (ALT 45 unit/L
d. High density lipoprotein (HDL) 75 mg/dl
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123. A nurse is reviewing the results of an ABG performed on a client with chronic emphysema. Which
of the following results suggests the need for further treatment?
a. paO2 level of 89 mm Hg
b. PaCO2 level of 55 mm Hg
c. HCO2 level of 25 mEq/L
d. pH level of 7.37
124. A nurse is teaching a client about nutritional intake. The nurse should include which of the
following in the teaching?
a. "Carbohydrates should be at least 45% of your caloric intake."
b. "Protein should be at least 55% of your calorie intake."
c. "Carbohydrates should be at least 30% of your caloric intake."
d. "Protein should be at least 60% of your caloric intake."
125. A nurse is caring for a client who has a prescription for vancomycin 1 g IV every 12 hr. The client
is scheduled to have the morning dose at 0700. The nurse should schedule the trough level to be drawn
at which of the following times?
a. 2100
b. 0900
c. 1300
d. 1800
126. A nurse is planning an education session for a client who has type 1 diabetes mellitus. Which of the
following should the nurse plan to include when teaching the client to monitor for hypoglycemia?
a. diaphoresis
b. polyuria
c. abdominal pain
d. thirst
127. A nurse in an urgent-care clinic is collecting admission history from a client who is 16 weeks of
gestation and has bacterial vaginosis. The nurse should recognize that which of the following clinical
findings are associated with this infection?
a. Frequency and dysuria
b. Profuse milky white discharge
c. Hematuria
d. Low grade fever
128. A nurse is planning care for a client who has a new diagnosis of dysphagia. Which of the following
foods should be included when initiating feeding?
a. beef broth
b. oatmeal
c. apple juice
d. toast
129. A nurse receives a change-of-shift report. Which of the following clients should the nurse attend to
first?
a. A client who reports tingling in the fingers following a thyroidectorny
b. A client who has dark, foul-smelling urine with a urine output of 320 mL in the last 8 hr
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c. A client who is in a long leg cast and reports cool feet bilaterally
d. A client who has a productive cough and an oral temperature of 36° C (96.80 F)
130. A nurse is caring for a client who has lactose intolerance and has eliminated dairy products from
his diet. The nurse should instruct the client to increase consumption of which of the following foods?
a. spinach
b. peanut butter
c. ground beef
d. carrots
131. A client who is 8 hr postpartum asks the nurse if she will need to receive Rh immune globulin. The
client is gravida 2, para 2, and her blood type is AB negative. The newborns blood type is B positive.
Which of the following statements is appropriate?
a. You only need to receive Rh immune globulin if you have a positive blood type."
b. You should receive Rh immune globulin within 72 hours of delivery."
c. "Both you and your baby should receive Rh immune globulin at your -week appointment."
d. "immune globulin is not necessary since this is your second pregnancy."
132. A nurse is caring for the mother of an adolescent who was killed in a motor-vehicle crash after a
school event. The mother states, I never should have let him take the car. Its all my fault!" Which of the
following responses by the nurse is appropriate?
a. You had no way of knowing this would happen."
b. Most parents blame themselves when losing a child."
c. Tell me why you feel this is your fault."
d. You appear to be feeling overwhelmed"
133. A nurse is educating a client about caloric intake and weight reduction. Which of the following
client statements indicates an understanding of the teaching?
a. “If I eat 500 fewer calories per day, I should lose 1 pound per week.”
b. “ If I eat 500 fewer calories per day, I should lose 1 pound per week."
c. "If I eat 450 fewer calories per day, I should lose 2 pounds per week."
d. "If I eat 250 fewer calories per day, I should lose 2 pounds per week."
e. "If I eat 300 fewer calories per day, I should lose 1 pound per week.”
134. A nurses is teaching post-operative care with the parents of a toddler following a cleft palate
repair. Which of the following should be included in the teaching?
a. Provide an orthodontic pacifier for comfort.
b. Offer fluids by using a straw.
c. Cleanse suture line with a cotton tip swab.
d. Remove elbow splints periodically to perform range of motion.
135. A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive
personnel?
a. Perform chest compressions during cardiac resuscitation.
b. Perform a dressing change for a new amputee.
c. Assess effectiveness of antiemetic medication.
d. Provide discharge instructions
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136. A nurse in an emergency department is serving on a committee that is reviewing the facility
protocol for disaster readiness. The nurse should recommend that the protocol include which of the
following as a clinical manifestation of smallpox?
a. Bloody diarrhea
b. Ptosis of the eyelids
c. Descending paralysis
d. Rash in the mouth
137. A nurse is preparing to perform closed intermittent bladder irrigation for a client following a
transurethral resection of the prostate (TURP). Which of the following actions is appropriate by the
nurse?
a. Aspirate the irrigation solution from the bladder.
b. Insert the tip of the irrigation syringe into the catheter opening.
c. Apply sterile gloves. 1296 in med surgical book
d. open the flow clamp to the irrigating fluid infusion tubing.
138. A nurse is caring for a client who has been taking haloperidol for several years. Which of the
following assessment findings should the nurse recognize as a long-term side effect of this medication?
a. Lipsmacking
b. Agranulocytosis
c. Clang association
d. Alopecia
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139. A nurse is planning care for a client who has Alzheimers disease and demonstrates confusion and
wandering behavior. Which of the following should the nurse include in the plan of care?
a. Place the client in seclusion when she is confused.
b. Request a prescription for PRN restraints when the client is wandering.
c. Dim the lighting in the clients room.
d. Leave one side rail up on the clients bed.
140. A nurse is reviewing the laboratory data of a client who has diabetes mellitus. Which of the
following laboratory tests is an indicator of long-term disease management?
a. Postorandial blood glucose
b. Glycosylated hemoglobin - Ha1c
c. Glucose tolerance test
d. Fasting blood glucose
141. A nurse on a pediatric care unit is delegating client care. Which of the following tasks should the
nurse delegate to an assistive personnel?
a. Initiate a dietary consult for a toddler.
b. Administer a glycerin suppository to a preschool-age child.
c. Evaluate gastric residual following intermittent feeding of an adolescent.
d. Transport a school-age child to x-ray.
142. A nurse is caring for a client who has been taking propranolol. Which of the following findings
indicates a need to withhold the medication?
a. sodium 130 mEq/L
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b. Blood pressure 156/90 mm Hg
c. Potassium 5.2 mEq/L
d. Pulse 54/min
143. A nurse working in a mental health facility observes a client who has bipolar disorder walk over to
a table occupied by other clients and knock their game off the table. Which of the following is an
appropriate response by the nurse?
a. Apologize to the others for your behavior."
b. I am disappointed that you continue to act out when you are angry."
c. Come outside with me for a walk."
d. If you dont calm down, you will have to go into seclusion."
144. A nurse is caring for a client who has human immunodeficiency virus (HIV) with neutropenia.
Which of the following precautions should the nurse take while caring for this client
a. Wear an N95 respirator while caring for the client.
b. Use a dedicated stethoscope for the client.
c. Insert an indwelling urinary catheter to monitor urinary output.
d. Monitor the client’s vital signs every 8 hr.
145. A nurse is checking laboratory results for a client. Which of the following laboratory findings
indicates hypervolemia?
a. serum sodium 138 mEq/L
b. Urine specific gravity 1.001
c. serum calcium 10 mg/dL
d. Urine pH 6
146. A nurse is caring for a group of clients in a long-term care facility. Which of the following
situations should the nurse recognize as a safety hazard?
a. A client’s wrist restraints tied to the bed rails
b. A clients bedside table placed across the foot of the bed
c. A meal tray left at the bedside from breakfast
d. A call light extension cord pinned to the bedspread
147. A nurse is caring for a client in a mental health facility. The clients daughter is crying and tells the
nurse that she feels guilty for leaving her father in the hospital. Which of the following is an
appropriate response?
a. I’d like to know more about what’s bothering you."
b. "Why are you feeling this way"
c. "You did the right thing by bringing him here."
d. "I’m sure your father doesn’t blame you."
148. A nurse is planning care for a client following gastric bypass surgery. The nurse should include
which of the following dietary instructions when preparing the client for discharge?
a. start each meal with a protein source.
b. Consume at least 25 g of fiber daily.
c. Check your blood glucose level before each meal.
d. Limit your meals to three times per day.
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149. 149 A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the
following findings requires intervention by the nurse?
a. Tidaling with spontaneous respirations
b. Drainage collection chamber is 1/3 full
c. 1 cm of water present in the water seal chamber
d. Suction chamber pressure of -20 cm H20
150. A provider has written a do not resuscitate order for a client who is comatose and does not have
advance directives. A member of the clients family says to the nurse, “I wonder when the doctor will
tell us what’s going on" Which of the following actions should the nurse take first
a. Request that the provider provide more information to the family.
b. Refer the family to a support group for grief counseling.
c. Offer to answer questions that family members have.
d. Ask the family what the provider has discussed with them.
151. A nurse is performing a skin assessment on a client who has risk factors for development of skin
cancer. The nurse should understand that a suspicious lesion is
a. scaly and red
b. asymmetric, with variegated coloring
c. firm and rubbery
d. brown with a wart-like texture
152. A nurse is interviewing an older adult client about the physiological changes he has been
experiencing. Which of the following changes should the nurse recognize is normally associated with
the aging process?
a. Decreased sense of taste
b. Decreased blood pressure
c. Increased gastric secretions
d. Increased accommodation to near vision
153. A nurse in an intensive care unit is planning care for a client who has alcohol withdrawal
syndrome. Which of the following should the nurse include in the plan of care?
a. Administer disulfiram.
b. Provide frequent orientation to time and place.
c. Engage the client in group therapy.
d. Perform gastric lavage.
154. A nurse is assessing a client’s cardiovascular system. Identify where the nurse should place the
diaphragm of the stethoscope to best hear the closing of the aortic heart valve. (Selectable areas or Hot
Spots" can be found by moving your cursor over the artwork until the cursor changes appearance,
usually into a hand. Click only on the Hot Spot that corresponds to your answer.)
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a. Top left site
155. A nurse manager is planning an audit to measure the quality of care on the unit. Which of the
following is the most appropriate source for the nurse to consult?
a. Nursing manager colleagues
b. Evidence-based practice data
c. Hospital administrators
d. Protocols in other hospitals
156. A nurse is caring for a client who had gastric bypass surgery 1 week ago and has signs of early
dumping syndrome. Which of the following findings should the nurse expect? (Select all that apply)
a. Facial flushing
b. Syncope
c. Diaphoresis
d. Vertigo
e. Bradycardia
157. A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings
should the nurse expect?
a. feelings of dread
b. rapid speech
c. purposeless activity
d. heightened perceptual field
158. A nurse is delegating tasks to an assistive personnel. Which of the following instructions
demonstrates appropriate communication of the task?
a. "Take a blood glucose fingerstick on the client in room 102 before breakfast and then place the
glucometer into the docking station."
b. "Obtain a blood pressure reading from the client in room 116 after lunch and report a systolic
level less than 90."
c. "Assist the client in room 110 to ambulate once around the unit and stop if she gets short of
breath."
d. "Turn the client in room 126 to prevent pressure areas on his hip bones."
159. A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood
pressure. The nurse should recognize that these findings are potential manifestations of which of the
following?
a. Nicotine withdrawal
b. Heroin intoxication
c. Alcohol withdrawal
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d. Amphetamine intoxication
160. A nurse is assessing an older adult client who had a stroke. Which of the following findings should
the nurse recognize as an indication of dysphagia?
a. Abnormal movements of the mouth
b. Inability to stand without assistance
c. Paralysis of the right arm
d. Loss of appetite
161. *A nurse is providing preoperative teaching to a client who will use PCA morphine sulfate
following surgery. Which of the following information should the nurse include?
a. The client should notify the nurse when administering a dose of the medication.
b. The client can administer a dose of medication every 6 to 8 min.
c. The client should be cautious to avoid overmedication (OD).
d. Family members can administer a dose the client.
162. A nurse is assisting the provider with a paracentesis for a client who has ascites. Following
collection of the specimen, which of the following actions should the nurse take next
a. Document the procedure.
b. Measure the drainage.
c. Record the color of the drainage.
d. Label the specimen.
163. A nurse is caring for a client in an inpatient facility who tells the nurse that she is leaving because
the facility policy prohibits smoking inside. Which of the following actions should the nurse take?
a. Notify security to monitor the facility exits.
b. Place the client in seclusion.
c. Inform the client of the risks involved if she leaves.
d. Call the provider for a discharge prescription.
164. A nurse is preparing to administer a measles, mumps, rubella (MMR) immunization to a child.
Which of the following is a contraindication for administration?
a. Recent blood transfusion
b. Allergy to penicillin
c. Minor acute illness
d. Low-grade fever
165. A nurse is preparing to administer 2.5 mL of medication intramuscularly to an adult client. Which
of the following is the safest site for the nurse to use?
a. Ventrogluteal
b. Dorsogluteal
c. Vastus lateralis
d. Rectus femoris
166. A nurse is teaching a female client how to reduce the risk of urinary tract infections (UTIs). Which
of the following should the nurse include as a risk factor for developing a UTI?
a. Wearing underwear with a cotton crotch
b. Wiping from front to back
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c. Using perfumed toilet paper
d. Urinating immediately after intercourse
167. A nurse is providing discharge instructions for a client who has a new prescription for furosemide.
Which of the following client statements indicates a need for further teaching?
a. "I will take my morning pills with food or milk."
b. "I will weigh myself every day."
c. "I will notify the nurse if I have muscle cramps."
d. "I will limit my intake of fish."
168. A nurse is caring for a client who has a prescription for atorvastatin. Which of the following client
conditions is a contraindication to this medication?
a. hepatits C
b. peptic ulcer disease
c. bronchitis
d. chrohn’s disease
169. A nurse is planning care for an adolescent who has chronic renal failure. Which of the following
actions should the nurse include in the plan of care?
a. Encourage a diet high in calcium.
b. Provide a diet high in potassium.
c. Ensure increased fluid intake.
d. Restrict protein intake to the RDA.
170. A nurse is assessing a client 1 hr following birth and notes that her uterus is boggy and located 2
cm above the umbilicus. Which of the following actions should the nurse take first?
a. Take vital signs.
b. Assess lochia.
c. Massage the fundus.
d. Give oxytocin IV bolus.
171. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the
following interventions should the nurse perform
a. Give 100 mL of water with every feeding.
b. Obtain gastric residuals every 24 hr.
c. Position the head of bed at 30 degrees during feeding.
d. Mix the clients medications with the tube feedings.
172. A nurse is caring for a 7 month-old infant who is being treated for severe dehydration. Which of
the following assessment findings indicates treatment has been effective?
a. Skin turgor displays tenting
b. Flat anterior fontanel
c. Cool, mottled skin
d. hyperpnea
173. A nurse is providing teaching to a client who has esophageal cancer and is scheduled to start
radiation therapy. Which of the following should the nurse include in the teaching?
a. Remove dye markings after each radiation treatment.
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b. Apply a warm compress to the irradiated site.
c. Wear clothing over the area of radiation treatment.
d. Use a washcloth to bathe the treatment area.
174. A nurse in a provider's office is providing education to a client who is 16 weeks of gestation and
has a new prescription for ferrous sulfate. Which of the following instructions should the nurse provide
a. Avoid strawberries, citrus fruit, and melon to ensure that your iron medication is effective."
b. "Take your iron medication with fluids other than coffee or tea."
c. "It is important to take your iron medication on a full stomach."
d. "If you miss a dose one day, take two doses the next day."
175. 175 A nurse receives a change-of-shift report on four clients. Based on the shift report information,
which of the following clients should the nurse plan to assess
a. A client who had a hip arthroplasty reports pain and erythema in his calf
b. A client who has anorexia and peripheral edema
c. A client who has Addison's disease with a blood glucose level of 75 mg/dL
d. A client who had a barium enema 2 days ago and reports constipation
176. A nurse administers a dose of metoclopramide to a client prior to chemotherapy treatment. Which
of the following medications should the nurse administer?
a. Albuterol sulfate
b. Hydromorphone
c. Diphenhydramine
d. Amitriptyline
177. A client who does not speak English arrives at the emergency department accompanied by a child.
Which of the following actions should the nurse take?
a. Ask the assistive personnel to assist the client in signing consent for treatment
b. Ask the child to interpret for the client.
c. Ascertain what language the client speaks and get an interpreter.
d. Try to find an adult relative to help the client communicate.
178. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate
intravenously. The nurse discontinues the magnesium sulfate after the client displays toxicity. Which of
the following actions should the nurse take?
a. Position the client supine.
b. Prepare an IV bolus of dextrose 5% in water
c. Administer calcium gluconate IV.
d. Administer methylergonovine IM.
179. A nurse is using Naegeles rule to calculate the expected delivery date for a newly pregnant
primigravida. The first day of the clients last period was October. What is the expected delivery date?
(Provide the date using four numerals, the first two for the month and the second two for the day. For
example, January 2 0102)
a. 0711 (July 7, 2011)
Formula: +1 year, -3 months, +7 days
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180. A nurse on a medical-surgical unit is receiving report on four clients. Which of the following clients
should the nurse assess first?
a. A client who is scheduled for chemotherapy and has a hemoglobin of 9
b. A client who is 24 hr postoperative following a transurethral resection of the prostate (TURP)
and has small blood clots in the urinary catheter
c. A client who is receiving a blood transfusion and reports low-back pain
d. A client who has a new colostomy with a reddish-pink stoma