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1. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for

which of the following complications?

a. Vomiting

b. Hypertension

c. Epigastric pain

d. Contractions (Rationale: post procedures notify HCP immediately for bleeding, contractions. ATI book pg 119.)

2. A nurse is providing teaching to an older client about methods to promote nighttime sleep. Which of the following instructions should

the nurse include?

a. Stay in bed at least 1 hr if unable to fall asleep

b. Take a 1 hr nap during the day

c. Preform exercises prior to bedtime

d. Eat a light snack before bedtime

3. A nurse on a telemetry unit is caring for a client who becomes unconscious and whose monitor displays ventricular

tachycardia. Which of the following actions should the nurse take first after determining the client does not have a palpable pulse?

a. Assess heart sounds

b. Defibrillate ( Rationale: V-tach= >150 bpm it decreases cardiac output, if there’s a pulse do a cardioversion but PULSELESS

you defibrillate)

c. Establish IV access

d. Administer epinephrine

4. A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding. The nurse does not speak the same

language as the client. The client’s partner and 10-year old child are accompanying her. Which of the following actions should the

nurse take to gather the client's admission data?

a. Have the clients child translate

b. Allow the clients partner to translate

c. Request a female interpreter through the facility

d. Ask a nurse student who speaks the same language as the client to translate

5. A nurse is caring for a client who is febrile. To reduce the clients fever, the nurse applies a cooling blanket. Which of the following

findings indicates the client is having an adverse reaction to the cooling?

a. Flushing

b. Tachycardia

c. Restlessness

d. Shivering

6. A nurse is caring for a client who has deep-vein thrombosis of the left lower extremity. Which of the following actions should

the nurse take?

a. Position the client with the affected extremity lower than the heart (elevate instead; arteries dangle, veins elevate)

b. Withhold heparin IV infusion

c. Administer acetaminophen (Rationale: TX; NSAID, heparin, Coumadin, thrombolytic, altepase pg 62 ATI book)

d. Massage the affected extremity every 4 hr

7. A nurse is reviewing assessment data from several clients. For which of the following clients should the nurse recommend referral to

a dietitian?

a. An older adult client who has a BMI of 24

b. A client who has a non healing leg ulcer

c. An older client who has presbyopia

d. A client who has an albumin level of 3.7 g/dL

8. A nurse is providing discharge teaching who has chronic kidney disease and is receiving hemodialysis. Which of the

following instructions should the nurse include in the teaching?

a. Eat 1 g/dL of protein per day (Diet is moderate protein (1-4g/dl), high carbs))

b. Take magnesium hydroxide for indigestion (cant excrete)

c. Drink at least 3 L of fluid daily (cant excrete)

d. Consume foods high in potassium (cant excrete, already in hyperkalemia)

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9. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for

aspiration?

a. Sitting in a high fowler's position during the feeding

b. A history of gastroesophageal reflux disease

c. Receiving a high osmolality formula

d. A residual of 65 mL 1 hr postprandial (residual has to be 500 ml> for risk for aspiration, NCLEX book says 250ml)

10. A nurse is providing parental 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 screening tests at 16 weeks of gestation?

a. Chorionic villus sampling (9-10wks)

b. Cervical cultures for chlamydia (1st trimester)

c. Nonstress test (3rd trimester)

d. Maternal serum alpha-fetoprotein ( done 16-18 wks, if decreased= down syndrome, if increased= neural tube defect)

11. A nurse is caring for a client who is on bed rest. The nurse should recognize that which of the following findings is a complication of

immobility?

a. Decreased serum calcium levels

b. Increased blood pressure

c. Swollen area on calf (Rationale: possible DVT)

d. Urinary frequency

12. A nurse in a acute care mental health facility is participation in a medication-education group. The leader of the group uses

a laissez-faire leadership style. Which of the following actions should the nurse expect from the leader during the session?

a. The leader encourages group members to remain silent until questions are called for

b. The leader lectures medication adverse effects to the group members

c. The leader allows the group to discuss whatever they would like to regarding their medications

d. The leader has group members vote on what they would like to learn about during the session

13. A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following

statements should the nurse include in the teaching?

a. “You can add the medication to half-cup of your child's favorite juice”

b. “Repeat the dose of your child vomits within 1 hr after taking the medication”

c. “Limit your child's potassium intake while she is taking the medication”

d. “Have your child drink a small glass of water after swallowing the medication”

14. A nurse is providing teaching to a client who has a depressive disorder and a new prescription for phenelzine. Which of the

following foods should the nurse instruct the client to avoid?

a. Grapefruit

b. Spinach

c. Cottage cheese ( has to be aged cheese for toxicity)

d. Smoked salmon (Rationale: avoid aged cheese, cured or smoke meat or fish, sauage, salami, beer, wine, soy,)

15. A nurse is planning care for a client who has COPD and weighs 99 lbs. The provider has prescribed a diet of 1.5 g

protein/kg/day. How many grams of protein per day should the nurse include in the client's dietary plan? (round the answer to the

nearest whole number. Use a leading zero if it applies. Do not use a trailing zero) 68g/day (Rationale: 99 /2.2= 45 x 1.5= 67.5

(68g/day)

16. A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following intervention should

the nurse include in the plan?

a. Encourage the client to spend time in the day room

b. Withdraw the client's TV privileges if he doesn't attend group therapy

c. Encourage the client to take frequent rest periods

d. Place the client in seclusion when he exhibits signs of anxiety

17. A parish nurse is leading a support group for clients whose family members have committed suicide. Which of the

following strategies should the nurse plan to use during the group session?

a. Initiate a discussion with clients about ways to cope with changes in family dynamics

b. Encourage clients to establish a timeline for their own grieving process

c. Discourage clients from sharing negative aspects of their relationship with the deceased persons.

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d. Assist clients in identifying ways suicide could have been prevented

18. A nurse manager observes two staff nurses reviewing the computer records of a client who is under their care. Which of

the following action should the nurse manager take first?

a. Instruct the nurses to close the client's computer record

b. Request the nurses present an in-service on client confidentiality

c. Place documentation of the nurses actions in the personnel file.

19. A nurse is reviewing the medical record of a client who has schizophrenia and ia taking clozapine. Which of the following findings

should the nurse identify as a contraindication to the administration of clozapine?

a. Heart rate 58/min

b. Fasting blood glucose 100 mg/dL

c. HgB 14g/dL

d. WBC count 2,900/mm

20. A nurse is caring for several clients on a medical-surgical unit. For which of the following nursing activities is it required that

the nurse use sterile gloves?

a. Inserting an NG tube

b. Administering total parenteral nutrition through a central venous access device

c. Initiating IV access

d. Performing tracheostomy care

21. A nurse is caring for a client who is at 11 weeks of gestation. Which of the following immunizations should the nurse

recommend? a. Influenza

b. Measles, mumps and rubella

c. HPV

d. Varicella

22. A nurse is inserting an indwelling urinary catheter for a male client. Which of the following actions should the nurse take?

a. Perform the cleansing procedure with a fresh swab two times

b. Lift the penis so that it is perpendicular to the clients body

c. Cleanse the tip of the penis in a side-to side motion

d. Pick up the catheter 13cm (5in) from its tip

23. A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of

the following findings should the nurse include in the teaching?

a. Bleeding gums

b. Faintness upon rising

c. Swelling of the face (Rationale: preeclampsia sign)

d. Urinary frequency

24. A nurse has received change of-shift report for a group of clients. Which of the following actions should the nurse take to

manage time effectively?

a. Document care at the end of the shift

b. Make a client to-do list for the day

c. Skip breaks until client tasks are completed

d. Focus on several clients tasks at a time

25. A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn

is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan?

a. Minimize noise in the newborns environment (Rationale: decrease stimuli, swaddle, feed freq meals,)

b. Administer naloxone to the newborn

c. Swaddle the newborn with his legs extended

d. Maintain eye contact with the newborn during feedings

26. The nurse is assessing the fontanels of an 8-month old infant. Which of the following should the nurse recognize as an expected

finding?

a. The anterior fontanel is open ( closes 12-18 months & diamond shaped)

b. The posterior fontanel is open

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c. Both fontanels are the same size

d. Both fontanels show molding

27. A nurse is caring for a client who has acute diverticulitis. Which of the following diets should the nurse recommend to the client?

a. High residue (fiber = residue)

b. Lactose free

c. Gluten free

d. Low fiber (Rationale: High fiber to prevent diverticulitis, low fiber during diverticulitis)

28. A nurse is caring for a client who is 48 hr postoperative following a total hip arthroplasty. Which of the following actions should the

nurse include in the plan of care?

a. Administer low dose heparin

b. Place the client on a full liquid diet

c. Use an incentive spirometer every 3 hr

d. Maintain the client on bed rest

29. A nurse is providing teaching to the parent of an infant who has a cleft lip palate. Which of the following feeding techniques should

the nurse include in the teaching?

a. Burp the infant frequently during feedings

b. Position the nipple at the from of the infants mouth

c. Hold the infant in a supine position

d. Use feeding devices without nipples

30. A nurse in an acute mental health care facility is prioritizing care for multiple clients. Which of the following clients should the

nurse see first?

a. A client who has depressive disorder and requires assistance with ADL’s

b. A client who has OCD and is upset about a change in daily routine

c. A client who is taking clozapine to treat schizophrenia and reports a sore throat

d. A client who has narcissistic personality disorder and is mocking others during group therapy

31. A nurse is planning care for a group of clients and is working with one LPN and one AP. Which of the following actions should

the nurse take first to manage her time effectively?

a. Develop an hourly time frame for tasks

b. Schedule daily activities

c. Determine goals of the day

d. Delegate tasks to the AP

32. A nurse is performing an admission assessment for a client who is in the manic phase of bipolar disorder. Which of the following

behaviors should the nurse expect?

a. Performance of ritualistic behaviors

b. Suspiciousness and distrust

c. Distractibility and poor judgment

d. Reports of physical discomfort

33. A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an

expected finding?

a. Weak femoral pulses

b. Frequent nosebleeds

c. Upper extremity hypotension

d. Increase ICP

34. A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include

when discussing borderline personality disorder?

a. The client might act seductively

b. The client is overly concerned about minor details

c. The client impulsive behavior

d. The client is exceptionally clingy to others

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