ATI RN Comprehensive Predictor Form F

Part b-2021

Comprehensive Predictor F

RETAKE

1. A nurse is caring for a client who has compartment syndrome following the application of a

tast to the leg. Which of the following.. nurse take?

Check the client's pedal pulses

Administer a dose of antlemetic medication Position

the client's leg above the level of the heart

.Apply ice to the extremity

2. A nurse is preparing to administer levothyroxine 50 micrograms to a client .Aavailable

levothyroxine 0.025 mg/tablet .How many table to the nurse administer per dose?

3. A nurse is providing teaching about home safety to the adult child of an older adult client who

is postoperative following knee replacementsurgery.Which of the following instructionsshould

the nurse include

Place a throw rug over electrical cords

Encourag the client to avoid wearing shoes at home Mark

the edges of the doorway to the house with tapeEnsure

that area rugs have rubber backs

4. A nurse manager isreviewing the steps of the progressive discipline process prior to counseling

a staff member who exhibits unprofessional behavior. Identify the sequence of steps the nurse

manager should plan to take in response to the staff member's conduct. (Move the steps into

the box on the right, placing them in order of performance. Use all the steps.)

2- Give the staff member a written earning about the behavior.

1- Verbally remind the staff member of the expected behavior changes.

4- Suspend the staff member from employment at the facility5-

Dismiss the staff member from employment at the facility.

3- Set up a meeting to speak with the staff member about the behavior.

5. A nurse is providing teaching to a client who has a multiple sclerosis . Which of the

following statement should the nurse include

Limit your daily intake of high fiber foods

Establish a voiding schedule by urinating exercises every 4 hours

Avoid exercises that increase your body temperature

Wear an eye patch over one eye for an entire day before switching

6. A nurse in an emergency department is caring for a toddler who has burns following

ahouse fire. Which of the following actions should the nurse take first?

Calculate the fluid replacement based on vital signs and urinary output

Determine the location and depth of burns

Administer antibiotics to prevent sepsis.

Check the mouth for smooth and smoky breath

7. A nurse is caring for a client who has a pressure injury on the coccyx .Which of

thefollowing should indicateto the nurse that… a stage III pressure injury ?

Bone is exposed within the wound

Shough and eschar is present

Subcutaneous fat is visible

The skin is reddened and intact

8. (OJO) 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?

Written prescription from the provider

Institutional policies and procedures

Verbal direction from the nurse manager

State Nurse Practice Act

9. A nurse is caring for a client who has a prescription for 1 unit of packed RBCS. Flve minutes

after beginning the transfusion… with chills. After stopping the transfusion, which of the

following actions should the nurse taket?

Infuse 500 mL lactated Ringer's Iv.

Adininister epinephrine subcutaneously.

Document the reaction in the medical record.

Place the blood bag in a biohazard bag before discarding

10. A Nurse is teaching participants at a community center about advance directives. Which of the

following information should the nurse include in the teaching?

Assigning a health care surrogate requires legal consultation

A client must create a do not resuscitate order when completing advances directives.

Advance directives cannot be changed once implemented.

A health care surrogate makes health care decisions when the client is no longer able.

11. A nurse is teaching a client who plans to begin following vegan dietary guidelines. Which of

the following Information should the nurse

Limit Intake of nuts and legumes.

Choose foods high in vitamin B12

Choose high-fat cheese as a meal substitute.

Limit Intake of foods high in vitamin C

12. OJO A nurse in an emergency department is assesing a client with major depressive

disorder. Which of t nurse take first? Exhibit

Obtain the clients weight

Administer ondansetron to the client for ma

Obtain a blood glucose level

Implement seizure precaution for the client

13. A nurse is assessing the grief response of a client whose child died 6 mONTHS age Which of

the following client statement should.. the provider as an Indication of major depressive

disorder?

I am unable to feel any joy since my child died.

I feel guilty because my child died

I now that will be reunited with my child somedayI

am angry that my child died.

14. A newly licensed nurse is reviewing the role of a nurse in disaster planning. Which of

thefollowing is an activity a nurse should engage in to assist in disaster preparedness?

Participate in community drills and mock events. Vaccinate

susceptible children and adults against smallpox Assess

types, levels and scopes of disasters.

Make quarantine preparations for those exposed to anthrax

Rationale: Assess First

15. A nurse is caring for a client who is experiencing acute mania. Which of the following

foods should the nurse provide for this client?

Peanut butter

sandwich Oatmeal with

butter Chicken noodle

soup Celery sticks

16. A nurse is admitting a client who has dementia to a long-term care facility. The client

tellsthe 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?

Agnosia

Projection

Perseveration

Confabulation

17. A nurse is providing dietary teaching to a client who had an exacerbation of COPD. which of

the following information should the nurse including in the teaching?

You should eat hot foods to reduce your sense of fulness during a meal.

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

18. A nurse is caring for four clients on a medical-surgical unit For which of the following clients

should the nurse complete a medication conciciliation ?

A client who has a prescription for a gallbladder sonogram

A client who transfers from a private room Into a semi-private roomA

client who received twice the prescribed dose of a medication

A client who returns to the unit from the PACU following surgery

19. A nurse is Initiating bladder retraining for a client who has urge urinary incontinence. Which

of the following instruction should the nurse…the client ?

Take your diuretic medication with your evening meal

Decrease your intake of cranberry juice

Pan to urinate every 3 hours while you are awake

Limit your fluid Intake to 500 milliters per day. "

20. A nurse realizes that the wrong medication has been administered to a client. Which

ofthe following actions should the nurse take first?

A. Notify the provider.

B. Report the incident to the nurse manager.

C. Measure the client vital signs.

D. Fill out an incident report.

21. A nurse is teaching a client who had a left below-the-knee amputation 3 days ago. The nurse

should identity that which of the following statement by the client Indicates an understanding

of the teaching?

I will change the wrapping on my left leg once a day at home

I Should avoid moving the joints in my left leg

I might still experience the feeling of numbness and brigling in my left

I can elevate my left leg on a pillow while lying in bed.

22. A nurse and an assistive personnel (AP) are assigned a group of clients on the unit. Which of

the Following clients should the nurse report to the nurse ?

A client who has a prescription for compression stockings and did not receive themA

client who consumes all the food from their meal tray

A client who requests assistance to use the bedside commode

A client who requests to sit in the bedside chair while watching TV

23. A nurse is preparing to obtain a client signature on an informed consent form. Which of the

following actions should the nurse…

Notify the provider if the client has questions about the procedure

Ask the client to explain his understanding of the procedure.

Inform the client of his right to change his mind witness

the client signing the informed consent form

24. A nurse is updating the plan of care for a client who has an exacerbation of psoriasis. Which

of the following intervention should the nurse include in the plan ?

Cover lesions with an occlusive dressing after applying a corticosteroid

Discontinue ultraviolet light therapy If lesions itchy

Scrub external lesions with a pumice stone

Instruct the client to add rubbing alcohol to bath water.

25. A nurse is caring for a client who received a large amount of heparin IV in error. Which of the

following laboratory should the nurse

aPT

T

INR

Ferritin level

Albumin level

26. (OJO) A nurse in an emergency department is caring for a client following a motor vehicle

crash . The client Glasgow coma scale,, following findings should the nurse expects?

The client opens eyes to sound

The client withdraws from pain.

The client Is oriented times three

The client is unable to obey commands

27. A client’s partner tells a staff nurse that he overhears laboratory staff discussing the

resultof 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

review confidentiality policies with laboratory employees- would be the job of the

Facility manager or someone who audits or teaches HIPAA stuff

contact the laboratory manager regarding the situation - you are not high enough up the chain

to do that

Notify the facilities legal department - no need to go that far

28. (OJO)A nurse is assessing a client who has a prescription for hydrocodone PRN . Which of

the following adverse effects should the nurse identify priority for withholding this medication

and notifying the provider ?

Constipation

Hypotension

Urinary retention

Nausea

29. A nurse is performing initial assessment of a newborn. Which of the following actions should

the nurse take to prevent any heat lost thro.. production?

Place the newborns crib away from of on air went to perform the assessmentEvaluate

respirations by observing the newborn's uncovered chest for 1 min Perform the

assessment inmediately after bith before removing amniotic fluidCover the scale with

a warmed blanket before weighing the baby.

30. A nurse is completing an incident report after a client fall. Which of the

following competencies of Quality and Safety Education for Nurse is the use

demonstrating?

A. Quality improvement.

B. Patient centered care

C. Evidence based practice.

D. Informatics.

31. A nurse is consulting a pharmacological reference about medication compatibility prior to

administering warfarin a client. Which of should the nurse identify as being incompatible with

warfarin?

Propranolol

Lisinopril

Magnesium hydroxide

Naproxen

32. A nurse is preparing to administer a blood transfusion to a client , Which of the following

actions should the nurse take ?

Use an IV catheter that is at least 24-gauge.

Prime the tubing with 0.9% sodium chloride.

Attach a single-line administration set.

Use tubing that does not have a filter in the drip chamber

33. A nurse is providing teaching to a client who has a new prescription for warfarin. The nurse

should include that which of following medications can increase the effects of warfarin ?

Nafcilin

Vitamin K

Oral contraceptives

34. 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.)

Caution staff that the equipment is complicated to use.

Wait to offer feedback on staff use of the equipment until the end of the session.

Identify the current level of staff knowledge about the equipment.

35. 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?

Take a bubble bath after intercourse

Void every 5 to 6 hr during the day

Drink four 240 mL (8 oz) glasses of water each day.

Wear loose-fitting underwear.

Require a return demonstration using the equipment.

Provide reinforcement of teaching until the skill islearned.

36. A nurse is providing teaching to a client who is scheduled for radiation therapy to treat

esophageal cancer. Which of the following the nurse make?

Drink mostly clear liquids.

"Use commercial mouthwashes to rinse your mouth.

Soften foods with gravy and sauces

Warm up foods before eating.

37. (OJO) A nurse is assessing a client who has heart failure and is prescribed a 2,000 m / 24 hr

fluid restriction .Which of the following fluid should the nurse report to the provider?

Watery stools of 400 ml in 8 hr

Oral intake of 300 ml in 8 hr

Urinary output of 420 ml in 8 hr

Intravenous intake of 240 ml in 8 hr

38. A nurse is helping to prepare a client in the operating room prior to a surgical procedure.

which of the following action should

Leave the client's arms and legs uncovered until after the induction of anesthesiaRemove

the client eyeglasses upon arrival to the operating room

Provide padding to the pressure point areas when positioning the client

Minimize conversation with the client to reduce anxiety

39. A nurse manager isreviewing the steps of the progressive discipline process prior to counseling

a staff member who exhibits unprofessional behavior. Identify the sequence of steps the nurse

manager should plan to take in response to the staff member’s conduct. (Move the steps into

the box on the right, placing them in order of performance. Use all the steps.)

Give the staff member a written earning about the behavior. (3) Verbally

remind the staff member of the expected behavior changes. (2)

Suspend the staff member from work for several day employment at the facility. (4)

Dismiss the staff member from employment at the facility. (5)

Set up a meeting to speak with the staff member about the behavior. (1)

40. 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 partner and

a 10-year-old child are accompanying her. Which of the following actions should the

nursetake to gather the client’s information?

Request a female translator interpreter through the facility

Ask a student nurse who speaks the same language to translateHave

the child translate

Allow the clients child to translate

41. 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?

Calculate the fluid replacement based on vital signs and urinary output

Determine the location and depth of burns

Administer antibiotics prophylactically to prevent sepsis.

Check the mouth for smooth and smoky breath

42. OJO A nurse is caring for a client who has heart failure. The nurse notes the client’s 24-hrintake is 1.750 mL and output is 425 mL. Which of the following actions should the nurse take

first?

Compare the client’s wight to the previous day.

Reduce the client’s sodium intake.

Encourage the client to change positions frequently.

Administer furosemide to the client.

43. A nurse is caring for a school-age child who has sickie cell anemia and is in vaso-acclusive

crisis. Which of the following action the nurse….

Increase oral fluid intake

Promote active range of motion exercises

Apply cold compresses to the affected areas

Prepare for a transfusion of platelets

44. A nurse is talking with another nurse on the unit and smells alcohol on her breath.

Which of the following actions should the nurse take?

A. Confront the nurse about the suspected alcohol use.

B. Inform another nurse on the unit about the suspected alcohol use.

C. Ask the nurse to finish administering medications and then go home.

D. Notify the nursing manager about the suspected alcohol use.

45. A nurse is assessing a client who is immediately post-operative following hip arthroplasty,

which of the following considerations should the nurse take when positioning the client?

A.Place the client’s heels directly against the bed mattress.

B.Ensure that the client’s hips remain in an abducted position.

C.Maintain the client in a supine position for the first 24 hr. after surgery.

D.Flex the client’s hip up to 120° when sitting in a chair.

46. OJO P[access device .Which of the following …. the child's family member Indicates

anunderstanding of the teaching?

I can expect my child to resume playing sports within 48 hours

"Twill replace the dressing in 24 hours with an occlusive dressing"

If my child develops an elevated temperature. I will contact you "I

should encourage a dally shower to keep the insertion site clean.

47. A nurse is caring for a client who wears glasses. Which of the following actions should

the nurse take?

A. Store the glasses in a labeled case.

B. Clean the glasses with hot water.

C. Clean the glasses with a paper towel.

D. Store the glasses on the bedside table.

48. A nurse is teaching a group of newly licensed nurses about measures to take when caring

for a client who is on contact precautions. Which of the following should the nurse include

in the teaching?

Remove the protective gown after leaving the client

Wear a mask when changing the linens in the client’s room.

Place the client in a room with negative air pressure

Wear gloves when providing care to the client.

49. A nurse is assessing a client who is immediately postoperative following a subtotal

thyroidectomy. Which of the following should the nurse expect to administer?

A.Calcium gluconate.

B.Sodium bicarbonate.

C.Potassium chloride.

D.Sodium phosphate.

50. The nurse is reviewing the medical record of a client who is requesting combination

oral contraceptives. Which of the following conditions in the client’s history is a

contradiction to the use of oral contraceptives?

A. Hyperthyroidism.

Thrombophlebitis.

C. Diverticulosis.

D. Hypocalcemia

.E.

51. A nurse is planning on care for a client who is recovering from an acute myocardial

infarction that occurred 3 days ago. Which of the following instructions should the nurse

include?

A.Perform an ECG every 12 hr.

B. Place the client in a supine position while resting.

C. Draw a troponin level every 4hr.

D. Obtain a cardiac rehabilitation consultation.

52. A nurse is assessing a client who is immediately post-operative following hip arthroplasty,

which of the following considerations should the nurse take when positioning the client?

A.Place the client’s heels directly against the bed mattress.

B.Ensure that the client’s hips remain in an abducted position.

C.Maintain the client in a supine position for the first 24 hr. after surgery.

D.Flex the client’s hip up to 120° when sitting in a chair.

53. A nurse is assessing a client who is immediately postoperative following a subtotal

thyroidectomy. Which of the following should the nurse expect to administer?

A.Calcium gluconate.

B.Sodium bicarbonate.

C.Potassium chloride.

D.Sodium phosphate.

54. A nurse is caring for an adult client who has prescriptions for multiple medications.

Which of the following (Unable to read) as an age-related change that increases the risk

for adverse effects from this medication?

A.Rapid gastric emptying.

B.Prolonged medication half-life.

C.Increased medication elimination.

D.Decreased medication sensitivity.

55. (Ojo) A nurse manager is planning to promote client advocacy among staff in a medical

unit. Which of the following actions should the nurse take?

A. Encourage staf f to implement the principle of paternalism when a client is having difficulty

making a choice.

B.

B. Tell staff explain procedures to clients before obtaining informed consent.

C. Instruct unit staff to share personal experiences to help clients make decisions.

56. A nurse is providing teaching to a client who has a new prescription for warfarin. The nurse

should include that which of the following medications can increase the effects of warfarin.

Nafcillin

Aspirin

Vitamin

k

Oral contraceptives

57. 101. 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?

Propranolol

Lisinopril

Magnesium hydroxide

Naprox…

58. A charge nurse is planning a staff education and competency session about operating newly

acquired cardiac monitoring equal. Which of the following actions should the nurse plan?

(Select all that apply.)

Wait to offer feedback on staff use of the equipment until the end of the sessionRequire

a return demonstration using the equipment

Caution staff that the equipment is complicated to use Provide

reinforcement of teaching until the skill is learned

Identify the current level os staff knowledge about the equipment

59. A nurse is caring for a client who is experiencing expressive aphasia and right

hemiparesis following a cerebrovascular accident. Which of the following actions by the

nurse best promotes communications among staff caring for the client?

Noting changes in the treatment plan in the client’s medical record

Recording the client’s progress in the nurses’ notes

Posting swallowing precautions at the head of the client’s bed

Having interdisciplinary team meetings for the client on a regular basis

60.A nurse is providing teaching about the gastrostomy tube feedings to the parents of

aschool age child. Which of the following instructions should the nurse take?

A.Administer the feeding over 30 min.

Place the child in as supine position after the feeding.

Charge the feeding bag and tubing every 3 days.

Warm the formula in the microwave prior to administration.

61. A nurse is administering digoxin 0.125 mg Po to an adult client. For which of the

followingfindings should the nurse report to the provider?

A. Potassium level 4.2

mEq/L.B. Apical pulse

58/min.

C. Digoxin

level 1 ng/ml.

nivel

D. Constipation

for 2 days.

62. 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?

E. Confront the nurse about the suspected alcohol use.

F. Inform another nurse on the unit about the suspected alcohol use.

G. Ask the nurse to finish administering medications and then go home.

H. Notify the nursing manager about the suspected alcohol use.

63. A nurse is caring for an adolescent who has sickle-cell anemia. Which of the

following manifestations indicates acute chest syndrome and should be

immediately reported to the provider?

A.Substernal retractions.

B. Hematuria.

C. Temperature 37.9 C (100.2 F).

D. Sneezing.

64. 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 nurse identify as indicating that the client is experiencing

maladaptive grieving ?

The client openly expresses anger when discussing the partner deathThe

client has joined a support group

The client reports having good and bed days

The client reports feelings of guilt about the partner death

65. 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 take?

Leave the client's arms and legs uncovered until after the induction of anesthesia.

Remove the cent's eyeglasses upon to the operating room

Provide padding to the pressure point areas when positioning the client

Minimize conversation with the client to reduce anxiety

66. A nurse is providing care for a client who is in the advance stage of amyotrophic

lateralsclerosis. (ALS). Which of the following referrals is the nurse’s priority?

A. Psychologist.

B. Social worker.

C. Occupational therapist.

D. Speech-language pathologist.

67. A nurse is reviewing the laboratory results of a client who has rheumatoid

arthritis. Which of the following findings should the nurse report to the

provider?

A.WBC count 8,000/mm3.

B. Platelets 150,000/mm3.

C. Aspartate aminotransferase 10 units/L. rate 5 a 40 units/L

D. Erythrocyte sedimentation rate 75 mm/hr para los hombres 0 a 22 y las mujeres de o a 29

68. A nurse is preforming a gastric lavage for a client who has upper gastrointestinal

bleeding. Which of the following action should the nurse take?

A.Instill 500 ml of solution through the NG tube.

B. Insert a large-bore NG tube.

C. Use a cold irrigation solution.

D. Instruct the client to lie on his right side.

69. A nurse is caring for a client admitted for alcohol use disorder who reports using alcohol nurse

take to assist the client… the nurse take to assist the client in maintaining self-control of the

behavior?

Provide the client with periods of alone time for reflection on their behavior

Discuss strategies with the client to reduce alcohol consumption gradually

Give positive feedback to the client for using adaptive coping strategies

Have the client's partner assume responsibility for monitoring the clients alcohol intake

70. A nurse is caring for a client who is comatose and has advance directives that indicate

the client does not want life-sustaining measures. The client’s family want the client to

have life-sustaining measures. Which of the following action should the nurse take?

Arrange for an ethics committee meeting to address the family’s concerns.

Support the family’s decision and initiate life-sustaining measures.

Complete an incident report.

Encourage the family to contact an attorney.

71. 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.

Clean the glasses with hot water. Clean

the glasses with a paper towel. Store the

glasses on the bedside table.

72. A nurse is providing discharge teaching to a client who has a new prescription for

phenelzine. The nurse should instruct the client that it is safe to eat which of the following

foods while taking this medication?

A. Avocados

b. Whole grain bread

c. Pepperoni pizza

d. Smoked salmon

73. A nurse is planning on care for a client who is recovering from an acute myocardial

infarction that occurred 3 days ago. Which of the following instructions should the nurse

include?

A. Perform an ECG every 12 hr.

E. Place the client in a supine position while resting.

F. Draw a troponin level every 4hr.

G. Obtain a cardiac rehabilitation consultation.

74. 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?

F. Hyperthyroidism.

Thrombophlebitis.

H. Diverticulosis.

I. Hypocalcemia.

75. A nurse is caring for a client who request the creation of a living will. Which of the following

actionsshould the nurse take?

A.Schedule a meeting between the hospital ethics committee and the client.

B. Evaluate the client’s understanding of life-sustaining measures.

C. Determine the client’s preferences about postmortem care.

D. Request a conference with the client’s family.

76. 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

Use commercial mouthwashes to rinse your mouth

Soften foods with gravy and sauces

Warm up foods before eating

77. A nurse is assessing a client who has heart failure and is prescribed a 2,000 Ml/ hr fluid restriction.

Which of the following fluids should the nurse report to the provider?

Water stools of 400Ml in 8 hr

Oral intake of 300 ml in 8 hr

Urinary output of 420 ml in 8 hr

Intravenous intake of 240 ml in 8 hr

78. A nurse is caring for a client who has colon cancer and is terminality III. The client states I can believe

going to die .Which of the following statement should the nurse make?

Tell me what is Important to you right now

Your doctor will make sure you wont be in much pain

I felt the same way you re feeling when my mother diedIt

might be comforting to pray for spiritual assistance

79. 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 Position

the casted extremity on a pillowPlace an

ice pack over the cast

Teach the client to keep the cast clean and dry

80. A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding, the

G.

nurse does not speak the same language as the client. The client partner and a 10-year-old child are

accompanying her. Which of the following actions should the nurse take to gather the client’s information?

a. Request a female translator interpreter through the facility

b. Ask a student nurse who speaks the same language to translate

c. Have the child translate

d. Allow the clients partner to translate

81. A nurse is caring for a client who has vision loss. Which of the following actions should the

nursetake? (Select all that apply)

A. Keep objects in the client’s room in the same place.

B. Ensure there is high-wattage lighting in the client’s room.

C. Approach the client from the side.

D. Allow extra time for the client to perform tasks.

E. Touch the client gently to announce presence.

82. A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions about

the disease. To research the nurse should identify that which of the following electronic database has

the most comprehensive collection of nursing (Unable to read) articles?

A. MEDLINE

B. CINAHL.

C. ProQuest.

D. Health Source.

83. A nurse in an emergency department is assessing newly admitted client who is experiencing

drooling and hoarseness following a burn injury. Which of the following should actions the nurse

take first?

A. Obtain a baseline ECG.

B. Obtain a blood specimen for ABG analysis.

C. Insert an 18-gauge IV catheter.

D. Administer 100% humidified oxygen.

84. A nurse is planning care for a client who has unilateral paralysis and dysphagia following a

right hemispheric stroke. Which of the following interventions should the nurse include in

theplan?

A.Place food on the left side of the client’s mouth when he is ready to eat.

B. Provide total care in performing the client’s ADLs.

C. Maintain the client on bed rest.

D. Place the client’s lef t arm on a pillow while he is sitting.

85. A nurse is caring for a client who is receiving brachytherapy for treatment of prostate cancer.

Whichof the following actions should the nurse take?

Limit the client’s visitors to 30 min per day.

Discard the client’s linens in a double bag.

Discard the radioactive source in a biohazard bag

Cleanse equipment before removal from the client room

86. A nurse is teaching a client about using a 3-point gait for crutch-walking. Which of the following actions

by the client understanding … teaching ?

Advances the affected leg first prior to the nonaffected leg

Uses both crutches when advancing the affected leg

Applies full weight on the affected side when advancing crutches

Planes weight on the axilla when advancing crutches

87. 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 partner and a 10-year-old child are

accompanying her. Which of the following actions should the nurse take to gather the client’s

information?

Request a female translator interpreter through the facility

Ask a student nurse who speaks the same language to translate

Have the child translate

Allow the clients child to translate

88. A nurse is caring for a client who is in labor and requires augmentation of labor. Which of the following

conditions should the nurse recognize as a contraindication to the use of oxytocin?

A. Diabetes mellitus.

Shoulder presentation.

Post term withhydramnios.

Chorioamnionitis

89. A nurse manager is reviewing the steps of the progressive discipline process prior to counseling a staff

member who exhibits unprofessional behavior. Identify the sequence of steps the nurse manager should

plan to take in response to the staff members conduct

Give the staff member a writing warning about the behavior Verbally

remind the staff member of the expected behavior changesSuspend the

staff member from work for several days

Dismiss the staff member from employment at the facility

Set up a meeting to speak with the staff member about the behavior

90. 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?

Applying a sterile gown after applying a sterile mask

Balancing the bottle on the sterile basin while pouring the liquid

Placing the supplies on the sterile filed and leaving a 1- inch perimeter

Putting on sterile gloves after preparing the sterile field

91. A nurse is assessing a client who has left-sided heart failure. Which of the following should

thenurse identify as a manifestation of pulmonary congestion?

A.Frothy, pink sputum.

B. Jugular vein distention.

C. Weight gain.

D..Bradypnea

92. A nurse is obtaining a clients manual blood pressure and is having difficulty auscultating sounds .Which of

the following actions should the nurse …?

Use the palpatory method to determine biood pressure

Deflate the cuff quickly

. Place the arm above the level of the client's heart

Apply the largest cuff available.

93. A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a

prescription for paternal fluid therapy. The guardian asks. “What are the indications that my baby

needs an IV?” Which of the following responses should the nurse make?

B. “Your baby needs an IV because her fontanels are budging”

C. “Your baby needs an IV because she is breathing slower than normal”

D. “Your baby needs an IV because her heart rate is decreasing”

94. A nurse is providing teaching to a client who has heart failure and a new prescription for

furosemide. Which of the following statements should the nurse make?

A. “Taking furosemide can cause your potassium levels to be high”

B. “Eat foods that are high in sodium”

D. “Taking furosemide can cause you to be overhydrated”

95. A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder.

Which of the following interventions should the nurse take?

A.Allow the client enough time to perform rituals.

B.Give the client autonomy in scheduling activities.

C.Discourage the client from exploring irrational fears.

D.Provide negative reinforcement for ritualistic behaviors

96. A nurse is caring for a client who has depression and reports taking ST. John’s wort along with

citalopram. The nurse should monitor the client for which of the following conditions as a result

of an interaction between these substances?

A. Serotonin syndrome

B. Tardive dyskinesia

A. “Your baby needs an IV because she is not producing any tears”

C. “Rise slowly when getting out of bed”

Pseudo parkinsonism.

C. Acute dystonia.

97. A nurse is caring for a client who isin a seclusion room following violent behavior. The client continues

to display aggressive behavior. Which of the following actions should the nurse take?

A.Confront the client about this behavior.

B. Express sympathy for the client’s situation.

C. Speak assertively to the client.

D.Stand within 30 cm (1 ft) of the client when speaking with them.

98. 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?

E. “Taking furosemide can cause your potassium levels to be high”

F. “Eat foods that are high in sodium”

G. “Rise slowly when getting out of bed”

H. “Taking furosemide can cause you to be overhydrated”

99. A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder.

Which of the following interventions should the nurse take?

A.Allow the client enough time to perform rituals.

B.Give the client autonomy in scheduling activities.

C.Discourage the client from exploring irrational fears.

D.Provide negative reinforcement for ritualistic behaviors

100. 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?

D. Serotonin syndrome

E. Tardive

dyskinesia Pseudo

parkinsonism.

F. Acute dystonia.

101. A nurse is caring for a client who is in a seclusion room following violent behavior. The client

continues to display aggressive behavior. Which of the following actions should the nurse take?

A. Confront the client about this behavior.

C. Express sympathy for the client’s situation.

C. Speak assertively to the client.

D.Stand within 30 cm (1 ft) of the client when speaking with them.

102. A nurse is calculating a client's expected date of delivery. The clients fast menstral period began

April 12

Using Nagele’s rule, what date should the nurse determine to be the client’s expected delivery date?

A nurse is discussing group treatment and therapy with a client. The nurse should include which of

the following as being a characteristic of a therapeutic group?

A.The group is organized in an autocratic structure.

B.The group encourages members to focus on a particular issue. (

C. The group must be led by a licensed psychiatrist.

D.The group encourages clients to form dependent relationships.

103. A nurse manger is reviewing documentation with a newly licensed nurse. Which of the following

notations by the newly licensed nurse indicates an understanding of the teaching?

UNSURE IF ON THE REPORT

A.“OOB with assistance for breakfast”

B. “Given 2 mg MSO4 IM for report of pain”

C. “Dressing changed qd”

D. “Administered 8 u regular insulin sq.”

104. A nurse is preparing to administer eye drops to a school-age child. Identify the actions the nurse

should take. (Move the steps into the box on the right, placing them in the order of performance. Use

all the steps.)

1. Apply pressure to the lacrimal punctum.5

2. Ask the child to look upward. 2

3. Pull the lower eyelid downward. 3

4. Instill the drops of medication. 4

5. Place the child in a sitting position. 1

105. A nurse is caring for a client who speaks a language different from the nurse. Which

ofthe following should the nurse take?

A. Request an interpreter of a different sex from the client.

B. Request a family member or friend to interpret information for the client.

C. Direct attention toward the interpreter when speaking to the client.

D. Review the facility policy about the use of an interpreter.

106. A nurse is caring for a client who is in labor and is receiving oxytocin. Which of

thefollowing findings indicates that the nurse should increase the rate of infusion?

ON THE REPORT needs double checking

A. Urine output 20 ml/hr.

A. Montevideo units constantly 300 mm Hg.

B. FHR pattern with absent variability.

C. Contractions every 5 min that last 30 seconds.

107. A nurse is planning care for a group of clients and is working with one licensed practical

nurse LPN and one assistive personal AP. Which of the following actions should the nurse

take first to manage her time effectively?

Develop an hourly time frame for tasks

Schedule daily activities

Determine goals of the day

Delegate tasks to the AP

108. A public health nurse is managing several projects for the community. Which of

the following interventions should the nurse identify as a primary prevention

strategy?

A.Teaching parenting skills to expectant mothers and their partners.

B. Conducting mental health screenings at the local community center.

C.Referring client who have obesity to community exercise programs.

D.Providing crisis intervention through a mobile counseling unit.

109. A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which

of the following statements by the client indicates an understanding of the teaching?

a. “I will take sucralfate with meals three times per day”

b. “I will avoid food and beverages that contain caffeine”

c. “I will decrease my daily protein intake to 15 grams per day”

d. “I will use ibuprofen as needed to control abdominal pain”

110. A nurse is assessing a client who is receiving packed RBCs. Which of the following

findings indicate fluid overload?

A.Low back pain.

Dyspnea.

Hypotension.

Thready pulse.

111. A nurse is providing teaching about patient-controlled analgesia (PCA) to a client.

Which of thefollowing statements should the nurse include in the teaching?

I. “The PCA will deliver a double dose of medication when you push the button twice.”

J. “You can adjust the amount of pain medication you receive by pushing on the keypad.”

K. “Continuous PCA infusion is designed to allow fluctuating plasma medication levels.”

L. “You should push the button before physical activity to allow maximum pain control.”

112. A nurse is preparing to administer an autologous blood product to a client.

Whichof the following actions should the nurse take to identify the client?

E. Match the client’s blood type with the type and cross match specimens.

F. Confirm the provider’s prescription matches the number on the blood component.

G. Ask the client to state the blood type and the date of their last blood donation.

H. Ensure that the client’s identification band matches the number on the blood unit.

113. A nurse is performing physical therapy for a client who has Parkinson’s disease. Which

of the following statements by the client indicates the need for a referral to physical

therapy?

B. “I noticed that I am having a harder time holding on to my toothbrush”

C. “Lately, I feel like my feet are freezing up, as they are stuck to the ground”

D. “Sometimes, I feel I am making a chewing motion when I’m not eating”

114. A nurse is reviewing laboratory data for a client who has chronic kidney disease.

Whichof the following findings should the nurse expect?

A.Increased creatine.

B. Increased

hemoglobin.

C.

Increased

bicarbonate.

D. Increased calcium.

115. A nurse is teaching at a community health fair about electrical fire prevention.

Which of thefollowing information should the nurse include in the teaching?

A. Use three pronged grounded plugs.

B. Cover extension cords with a rug.

C. Check the tingling sensations around the cord to ensure the electricity is working.

D. Remove the plug from the socket by pulling the cord.

116. A charge nurse is recommending postpartum client discharge following a local

disaster. Which of the following should the nurse recommend for discharge?

B. A 15-year-old client who delivered via emergency cesarean birth 1 day ago.

C. A client who received 2 units of packed RBCs 6 hr. ago for a postpartum hemorrhage.

D. A client who delivered precipitously 36 hr. ago and has a second-degree perineal laceration.

E. A 42 yoars old client who has preeclampsia and BP of 166/110 mmHG

117. A nurse is administering a scheduled medication to a client. The client reports that the

medication appears different than what they take at home. Which of the following

responses should the nurse take?

137 “I recommend that you take this medication as prescribed”

138 “Do you know why this medication is being prescribed to you?”

139 “I will call the pharmacist now to check on this medication”

Did the doctor discuss with you that there was a change in this medication

118. A community health nurse is developing a plan to improve the communitys environmental

health.which of the following action nurse take first?

Establish a timeframe for environmental improvements.

Encourage community Involvement in environmental improvement

Request funding from community organizations

Collect information about the community's environmental status

119. 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?

E. Withhold the next dose.

F. Increase the dosage.

G. Discontinue the medication.

H. Administer the medication.

120. A nurse in a clinic is assessing a 6-month-old infant. Which of the following should the

nursereport to the provider?

Pulse 140/min

Closed anterior

fontanelRespiratory rate

26/min Abdominal

breathing

121. A nurse is reviewing legal issues in health care with a group of newly licensed nurses. Which

ofthe following recommendations should the nurse make?

Place copies of incident reports in client’s medical records

Overestimate clients acuilty to prevent short staffing

Ensure that each client has a living will on file prior to treatment

Obtain personal professional liability insurance coverage

122. A nurse is planning care for a child who has neutropenia due to leukemia. Which of the

followingInterventions should the nurse Include in the plan of care?

Screen the child's visitors for active Infections.

Initiate Prepare the child for a platelet transfusion.

Prepare the child for a platelet transfusion.

Monitor the child for indications of active bleeding

123. A nurse is caring for a client who is near the end of life and is on complete bed rest. The client states

that heneeds to have a bowel movement and the nurse offers a bed pan. 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 bed pan.”

“I will have the physical therapist ambulate you to the

bathroom.”“You have to use the bed pan for you own safety.”

“Make sure to use nearby furniture to support yourself when walking to the bathroom.

124. A newly licensed nurse is unsure if an assigned task is within their scope of practice. which of the

followingresources should the nurse consult?

Written prescription from the provider

Institutional policies and procedures

Verbal direction from the nurse

managerState Nurse Practice Act

125. A Nurse is teaching participants at a community center about advance directives. Which of the

followinginformation should the nurse include in the teaching?

Assigning a health care surrogate requires legal consultation

A client must create a do not resuscitate order when completing advances directives.

Advance directives cannot be changed once implemented.

A health care surrogate makes health care decisions when the client is no longer able.

126. A nurse is reviewing the facility’s safety protocols considering newborn abduction with the

parentof a newborn. Which of the following statements indicates an understanding of the teaching?

I. “Staff will apply identification band after first bath”

J. “I will not publish public announcement about my baby’s birth”

K. “I can remove my baby’s identification band as long as she is in my room”

L. “I can leave my baby in my room while I walk in the hallway”

127. A nurse is planning care for four clients who are at risk for fluid imbalances. The nurse should

identity thatwhich of the following client for fluid volume excess?

A client who has ulcerative colitis

A client who has an exacerbation of peptic ulcer disease

A client who has diabetes insipidus

A client who has advanced stage liver cirrhosis

128. A nurse is caring for a client receiving mechanical ventilation via an endotracheal tube The high pressure

alarmis beeping and the.. experiencing respiratory distress. the nurse is unable to determine the cause pf the

alarm. Which ofthe following actions should the nurse …

Deliver breaths manually with a resuscitation bag

Decrease the ventilation flow rate

Reevaluate the client for an ET cuff leak

Assess for disconnected tubing

129. A nurse on a mental health unit is admitting a client who has posttraumatic stress, disorder.Which of the

followingshould the nurse expect ?

Experiences frequent grandiose thoughts

Talks continuously about the event

has difficulty concentrating on a task

Preoccupled with having a serious illness

130. A nurse is verifying a record of informed consent for a client who is sheduled for surgery .Which of the

followingactions should the nurse ….?

Inform the client about the condition that requires teatment

Confirm the client's signature Is authentic

Explain the procedure to the client before verifying informed

Provide Information on the informed consent form about the benefits of the surgery

131. A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy

toobtain a copy of the therapist’s notes. Which of the following responses should the nurse make?

We can provide a copy of your records, but the therapists notes are not includedI

don’t think you will benefit from reviewing your therapists notes right now Why

are you interested in seeing your therapist’s notes?

Are you not happy with your treatment?

132. A nurse is screening food brought in by a family member for a client who takes phenelzine. The nurse

shouldinstruct the family members…of the following foods can cause an interaction with this medication

?

Cottage cheese

loeberg lettuce salad

bologna sandwich

Orange gelatin

133. A nurse is assessing a client who is in skeletal traction for a fractured left tibia.The nurse should

identify thatwhich of the following … altered tissue perfusion of the affected extremity ?

Faint pedal pulse of left leg

Warm sidn temperature distal to pin site

Pain with movement of the left great toe

Purulent drainage at the pin site

134. A nurse is caring for a client who has bipolar disorder. Which of the following behaviors should the nurse

identifyas indicating the client experiencing mania ?

The client speaks using echopraxia

The client speaks using word salad.

The client is easily distracted by external stimuli

The client is socially withdrawn

N.

135. A nurse is obtaining a urine specimen from a client who has had an indwelling urinary catheter for

three days.Which of the following action should the nurse take after collecting the specimens?

Remove gloves after labeling the specimen

Place the specimen in a biohazard bag for transport

Obtain the specimen from the drainage collection

bag Wipe the outside of the specimen container with

alcohol

136. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of

thefollowing should the toddler participate?

M. Looking at alphabet flashcards.

Playing with a large plastic truck.

O. Use scissors cut out paper shapes.

P. Watching a cartoon in the dayroom.

137. A nurse is reviewing the cardiac rhythm of a client who is ….. on indication ventricular

tachycardia?P wave present with every QRS complex

Sowtooth shaped P

waves PR interval of 0.24

seconds

QRS complexes wider than 0.15 seconds

138. A nurse is admitting an older adult client who is transferring from another facility. The nurse notes

pressure ulcers on the client’s coccyx and abrasions around the wrists. Which of the following actions

should the nurse take to address the suspicions of elder abuse?

Inform the transferring agency of the client’s condition.

Privately interview the client about her condition.

Notify risk management

Contact the family regarding the client’s condition.

139. community health nurse is reviewing laboratory reports for a group of client. The nurse should identify

that whichof the following disorder on the CDC's Nationally Notifiable Conditions list!

Bacterial

vaginosis Lyme

disease

Respiratory syncytial

virusPediculosis capitis

140. A nurse is teaching a client who is trying to conceive. Which of the following should the nurse

instruct in her diet to prevent a neural tube defect?

Folate

Zinc

Iron

Calciu

m

141. 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

142. A Nurse is preparing to administer PRN pain medication to a client who has cholelithiasis and

experiencing moderate abdominal pain. Which of the following medications should the nurse plan to

administer?

Omeprazole

Ketorolac

Acetaminophe

n

Metoclopramid

e

143. A nurse is giving an intramuscular injection to a newborn who has delivered at 38 weeks of gestation

.Which ofthe following pain scale should the nurse use to assess the newborn pain ?

FACE pain rating scale

Premature Infant Pain Profile

(PIPP)Visual analog scale (VAS)

Neonatal Infant Pain Scale (NIPS)

144. A nurse is admitting a client who does not speak the same language as the nurse and scheduled for

outpatientsurgery. Which of following actions should the nurse take?

Request a family member to interpret the information.

Explain the procedure to the client through an

interpreter.

Provide consent form that is written in the client’s own language.

Help the client look up the information about the procedure on the internet

145. A nurse is preparing to initiate IV therapy for an older adult client. Which of the following actions

should thenurse plan to take ?

Clean the site using vigorous friction

Apply a tourniquet firmly above the

insertion Use 22-gauge catheter for

insertion

Select a vein on the back of the hand

146. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of

the following medications should the nurse administer?

Pregabalin

Lorazepam

Colchicine

Codeine

147. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a

referral to a dietitian

A. A client who has a prescription for warfarin and states “I will need to limit how much spinach I

eat”.

A client who has gout and states, “I can continue to eat anchovies on my pizza.”

C. A client who has a prescription for spironolactone and states “I will reduce my intake of foods that

contain potassium”.

D. A client who has (Unable to read) and states “I’ll plan to take my calcium carbonate with a full glass

of water”.

148. A nurse is reviewing the medical record of a client who has a prescription for intermittent heat

therapy for a foot injury. Which if the following findings should the nurse identify as a

contraindication for heat therapy?

Phlebitis

Abdominal aortic aneurysm

Osteoarthritis

Peripheral neuropathy

149. A nurse is planning teaching for a client who has a new diagnosis of HIV. Which of the following

informationshould the nurse include about preventing the spread infection?

Clean blood contaminated surfaces with

bleach.Use condoms with a petroleum-based

lubricant.Wash soiled clothes in cold water.

Buy disposable dishes for daily use.

150. A nurse is caring for a client who is receiving continuous enteral feedings. which of the following actions

shouldthe nurse take? Select

Check placement of the feeding tube by x-ray once daily

Maintain the head of the client's bed at a30% angle or

higherCheck gastric residuals every 4 hr.

Change the feeding container and tubing every 24

hr. Ensure the formula is cold before

administration

151. Anurse is assessing a client who has bipolar disorder and is experiencing depressive episode. which

of thefollowing findings should the nurse expect?

Clent expresses ilusions of grandeur

Inability to carry out a simple task

Client reports auditory hallucinations

Moves quickly from one idea to the

next

152. A nurse is caring for a client who is postoperative immediately following a cardiac catheterizacion

with a rightfemoral appro..Which of the following actions should the nurse take?

Elevate the head of the client's bed to 45

Assess the client's peripheral pulses every 15 min.

Change the client's dressing 4 hr following the

procedure.Instruct the client to flex the right knee

every 30 min.

153. 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 by the client indicates an understanding of the use of distraction?

B.

I will have electrodes inserted in my skin to treat the pain

I should apply my heating blanket to my back to reduce tension

I should jog every morning to improve my circulation

I will watch my favorite old movies when I want to reduce stress

154. A nurse is providing dietary teaching to a client who has hyperlipidemia .The nurse should include in the

teachingthat which obtains she lowest amount of saturated fats ?

Coconut

oil Olive

oil Canola

oil Palm

oil

155. A nurse is reviewing assessment data from several clients. For which of the following clients should

the nurse referral to a dietitian?

An older adult client who has a BMI of 24

A client who has a nonhealing leg ulcer An

older adult client who has presbyopia

A client who has an albumin level of 3.7g/Dl

156. A nurse isteaching a childbirth education class and is discussing sexual intercourse during pregnancy.

Whichof the following statements should the nurse make?

“The female superior position can be used during the third trimester of

pregnancy.”“Frequent intercourse increases the risk for miscarriage in early

pregnancy.”

“You should limit the frequency of intercourse after weeks of

pregnancy.”Yoursexual desire might increase during the first trimester

of pregnancy.”

157. A nurse is caring for an older adult client in a long-term care facility, recently lab values shows

increasedhemoglobin, hematocrit, and urine irregularity which findings suggest anemia

Anemia.

Dehydration

Hepatic failure

Acute renal

failure

158. A nurse is creating a plan of care for a female client who has recurrent urinary tract infections. Which

of thefollowing interventions should the nurse include in the plan?

Take a bubble bath after

intercourseVoid every 5 to 6 hr

during the day

Drink four 240 mL (8 oz) glasses of water each

day.Wear loose-fitting underwear.

159. 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.)

Caution staff that the equipment is complicated to use.

Wait to offer feedback on staff use of the equipment until the end of the session.

Identify the current level of staff knowledge about the equipment.

Require a return demonstration using the equipment.

Provide reinforcement of teaching until the skill islearned.

H.

160. A nurse is providing teaching to a client who is experiencing preterm contractions and

dehydration. Which of the following statements should the nurse make?

G. “Dehydration is treated with calcium supplements”

“Dehydration can increase the risk of preterm labor”

I. “Dehydration associated gastroesophageal reflux

J. “Dehydration is caused by a decreased hemoglobin and hematocrit”

161. A nurse is preparing a change of shift report for an adult female client who is postoperative.

Whichof the following client information should the nurse include in the report?

CONFIRMED

Hgb 12.8 g/dl - 12- 16

Potassium 4.2 meq/l 3.5 - 5.0 meq

RBC 4.4 million/mm3

Platelets 100,000/mm3

162. A nurse is caring for a client who tells the nurse that he feels he is being discharged from the facility too

soon

.which of the following the nurse demonstrate client advocacy?

I will contact your insurance company to see if they will pay for you to be have

longer?Your provider understands your illness and is acting according to your best

interests

I will that the provider about your concerns

I know you will be able to recover faster at home

163. A nurse is teaching a group of clients who are planning to have bariatric surgery. Which of the following

statements by a client indicated an understanding of the teaching?

“I will consume 48 ounces of carbonated beverages daily prior to the

surgery.”“I will need to lose 25 percent of my excess body weight prior to

surgery.”

“I should reduce my daily caloric intake by 250 calories to lose 2 pounds each week after

surgery.”“I should wait 30 minutes after eating solid foods to drink beverages following

surgery.”

164. A nurse is caring for several clients on a medical-surgical unit. For which of the following

nursingactivities is it required that the nurse use sterile gloves?

Inserting an NG tube

Administering total parenteral nutritional through a central venous access device

Initiating IV access

Performing tracheostomy care

165. A nurse in a surgical clinic is providing teaching to a client who is scheduled for a modified radical

mastectomy.Which of the following statements by the client indicates an understanding of the teaching?

“I can begin to drive 24 hours after surgery.”

“I can shower within 48 hours of my surgery.”

“I will have my drains removed 1 hour prior to going

home.”‘I will complete my arm exercises four times a

day.”

166. A nurse is teaching a client who has systemic lupus erythematosus (SLE). Which of the following

statements bythe client indicates an understanding of the teaching?

“I should apply power to my skin after

showering.”“I will not able to go for my daily

walk.”

“I will cleanse my skin using a mild soap.”

“I should check my skin once weekly for rashes.”

167. A nurse is providing discharge teaching to a female client who has tuberculosis and a new

prescription forrifampin. Which of the following information should the nurse include?

“Your urine will be orange while this medication.”

Weight gain is an expected adverse effect of this medication

You should avoid getting pregnant for 6 months after stooping this

medicationYou should avoid sun exposure while taking this medication

168. A nurse is providing discharge Instructions to a client who has a new prescription for spironolactone

.Which ofthe following the nurse include in the teaching?

Monitor weight once a week

Take the medication in the

morningUse a salt substitute with

meals

Administer a potassium supplement daily

169. 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?

Atorvastatin

Amoxicillin

Enoxaparin

Interferon beta1a

170. A nurse is caring for a client who has a history of depression and is experiencing a situational

crisis.Which of the following actions should the nurse take first?

A. Confirm the client’s perception of the event

B. Notify the client’s support system

C. Help the client identify personal strengths

D. Teach the client relaxation techniques

171. A nurse is counseling a group of clients from a town that was affected by a hurricane 6 months ago. For

which ofthe following clients should the nurse initiate a referral to assess for the presence of posttraumatic

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 expresses a realization that life will not return to the way it was before the hurricane.

A client who moved to an apartment located on higher ground than her previous home.

A client who describes feeling disconnected from those around him following the hurricane.

172. A nurse is caring for a client who has cancer of the throat and is receiving radiation therapy. The nurse

shouldmonitor for which of the following finding as an adverse effect of the radiation?

Excessive

salivation

Insomnia

Altered sensation

Elevate platelet

count

173. A nurse is providing teaching to a client who is breastfeeding and experiencing engorgement. Which

of thefollowing recommendations should the nurse include?

Wear a tight-fitting underwire bra.

Apply warm compresses on the breasts before

feedings.Allow the infant to nurse on one breast per

feeding.

Take aspirin to reduce pain and swelling.

174. A nurse is a community clinic is caring for client who request assistant with smoking censation The nurse

shouldexpect a prescription for which of the following medications?

Bupropion

Chiordiazepoxi

de Naltrexone

Clonidine

175. A nurse is preparing to administer an IV medication to a client and accidently punctures the IV bag

causing the medication to leak on the counter. Which of the following medications requires the nurse

to follow facility procedures in the safe handling of biohazardous material spill?

Doxorubicin hydrochloride

Ampicillin sodium

Metronidazole

Phenytoin

107. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse

planto take?

Obtain the newborn’s body temperature using a tympanic thermometer.Assess

the newborn pain level using 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.

108. 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 SQ every 4 hr. PRN for pain.”

“Morphine 3 mg Subcutaneous every 4 hr PRN for pain

“Morphine 3.0 mg sub q every 4 hr. PRN for pain.”

“Morphine 3 mg SC q 4 hr. PRN for pain.”

109. A nurse is caring for a client who has gestational hypertension and is experiencing toxic effects due to

magnesiumsulfate therapy. The nurse should anticipate administering which of the medications?

Calcium gluconate

Sodium

bicarbonate.

Potassium

chloride.

Magnesium citrate

110. A nurse is reviewing the formulary about NPH insulin before administering the medication to a client.

Which of thefollowing information the nurse expect ?

Administrer NPH Insulin 30min before

breakfast.Give NPH Insulin by IV bolus

Use NPH insulin to treat ketoacidosis

Discard the NPH insulin vial if the medication is cloudy

111. A nurse is planning care for a school age child who is 4 hr postoperative following appendicitis .Which of the

followingaction should the nurse include in the plan of care ?

Administer analgesics on a scheduled basis for the first

24 hrApply a warm compress to the operative site once

daily Offer small amounts of dear liquids 6 hr following

surgery Give cromolyn nebulized solution every8 hr

112. A nurse is preparing to admit a client who is 35 weeks of gestation for evaluation of the fetal well being due to

potencialpreterm labor following places of equipment should the nurse use to evaluate the fetal heart rate?

Intrauterine pressure

catheterSpiral electrode

Toco transducer

ultrasound

transducer

113. A nurse is reviewing the medical record of a client who has delayed healing of a leg ulcer. Which of the

followingfindings should the nurse identify as a contributing factor?

The client takes prednisone for arthritis.

The client is receiving IV dextrose 5% in water at 100

mL/hr.The client has a total cholesterol level of 190

mg/dL.

The client has an albumin level of 3.8 g/dL

114. A nurse is caring for a client who has hypertension and a new prescription for chlorthalidone. The nurse should

monitorfor which of the following adverse effects?

Hypoglycem

ia

Hypokalemi

a Euphoria

Increased intraocular pressure

115. A nurse is providing discharge instructions about newborn safety to a client who is 2 days postpartum. Which

of thefollowing instructions should the nurse include?

Change smoke detector batteries every other year.

Lay the baby on his stomach to nap during the

daytime.Use a car seat when traveling by airplane

Place a plastic waterproof sheet over the crib bedding.

116. A nurse is caring for a client who is 12 hr postoperative following aortofemoral bypass surgery .which of the

followingfinding should the nurse impact in the affected extremity?

Cool

extremities

Pedal pulse of

2+ Throbbing

pain

Capillary refill of 4 seconds

117. A home health nurse is teaching a new parent about caring for his 1-week-old-infant. Which of the following

statementsby the client indicates an understanding of the teaching?

“I can use a form pillow to prop up the bottle when feeding my

baby.”“I will avoid picking up my baby too often to keep from

spoiling him.” “I will hang a pastel-colored mobile 24 inches

above my baby’s crib.”

“I will place a ticking clock nearly to soothe my baby throughout the day.”

118. 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.

Wipe urine from the skin using a cool cloth

Apply talcum powder to the irritable area

119. A nurse is assessing a client who is receiving daily aspirin therapy .The nurse should identify that which of the

followingallergic reaction to this medication ?

Difficulty

swallowing Blurred

vision Weight gain

High blood pressure

120. A nurse is preparing to measure a temperature of an infant. Which of the following action 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 (1.5in) into the infant’s rectum.Insert

the thermometer in front of the infant’s tongue.

121. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary

recommendations should the nurse make?

Q. Coffee with creamer.

R. Lettuce with sliced avocados.

S. Broiled skinless chicken breast with brown rice.

T. Warm toast with margarine.

122. A nurse in a provider’s office is reviewing a female client’s medical record during a routine visit. The

nurse should recommend increasing dietary intake of which of the following vitamins? (Exhibit) --only

tab shown is Tab 3:

a. Vitamin D

b. Vitamin K

c. Vitamin A

d. Vitamin B12

123. A nurse is assessing a client who is 30 min postoperative following an arterial

thrombectomy. Which of the following findings should the nurse to report?

Chest pain

Muscle spasms.

Cool, moistskin.

Incisional pain.

124. A nurse is providing teaching to a client who is to begin external radiation therapy for cancer .Which of the

followinginformation include ?

Wash your skin thoroughly with a washcloth after each

treatmentWear a binder over the radiation site

You might experience altered taste

sensations Use rubbing alcohol to remove the

ink maricings

125. A nurse is caring for an infant who has respiratory svncytial virus . Which of the following intervention should

the nursetake ?

Suction nares prior to feeding

Request a prescription for

guaifenesin

Administer palivizumab

intravenously Initiate neutropenic

precautions

126. 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?”

“Why do you think your partner’s symptoms are progressing so quickly?”

“You should make sure your partner takes the prescribed medication.”

“You did the right thing by bringing your partner in for treatment.”

127. A nurse in a provider’s office is reviewing the laboratory results of a group of clients. The nurse should

identify that which of the following sexually transmitted infections is a nationally notifiable infectious

disease that should be reported to the state health department?

A. Chlamydia

B. Human papillomavirus

C. Candidiasis

D. Herps simplex virus

128. A nurse is caring for a client who is recovering from an amputation of her right arm below the elbow. Which

of thefollowing information should the nurse report to the occupational therapist?

The client’s parent is in a skilled nursing facility

The client is allergic to penicillin

The client has two small children at home

The client lives in a two-story home

129. A nurse is caring for a client who has heart failure. The nurse notes the client’s 24-hr-intake is 1.750 mL and

output is425 mL. Which of the following actions should the nurse take first?

Compare the client’s wight to the previous

day.Reduce the client’s sodium intake.

Encourage the client to change positions

frequently.Administer furosemide to the client.

130. A nurse in a mental health facility receives change-of-shift report for four clients. Which of the following clients

shouldthe nurse plan to assess first?

A newly admitted client who has a hx of 4.5 kg (10lb) weight loss in the past 2 monthsA

client who will be receiving her first ECT treatment today

A client placed in restraints due to aggressive behavior

A client who received a PRN dose of haloperidol 2 hr ago for increased anxiety

131. A nurse is caring for a newborn who is experiencing neonatal abstinence syndrome. which of the following

actionsshould the nurse take

Decrense the lighting levels in the

nurseryWrap the newborn loosely in a

bianket

Encourase frequent eye contact with the newborn during

feedingProvide frequent stimulation for the newborn

176. A nurse is calculating a client's expected date of delivery. The clients fast menstral period began

April 12

Using Nagele’s rule, what date should the nurse determine to be the client’s expected delivery date?

A nurse is discussing group treatment and therapy with a client. The nurse should include which of

the following as being a characteristic of a therapeutic group?

A.The group is organized in an autocratic structure.

B.The group encourages members to focus on a particular issue. (

C. The group must be led by a licensed psychiatrist.

D.The group encourages clients to form dependent relationships.

177. A nurse manger is reviewing documentation with a newly licensed nurse. Which of the following

notations by the newly licensed nurse indicates an understanding of the teaching?

UNSURE IF ON THE REPORT

A. “OOB with assistance for breakfast”

E. “Given 2 mg MSO4 IM for report of pain”

F. “Dressing changed qd”

G. “Administered 8 u regular insulin sq.”

178. A nurse is preparing to administer eye drops to a school-age child. Identify the actions the nurse

should take. (Move the steps into the box on the right, placing them in the order of performance. Use

all the steps.)

6. Apply pressure to the lacrimal punctum.5

7. Ask the child to look upward. 2

8. Pull the lower eyelid downward. 3

9. Instill the drops of medication. 4

10. Place the child in a sitting position. 1

179. A nurse is caring for a client who speaks a language different from the nurse. Which

ofthe following should the nurse take?

E. Request an interpreter of a different sex from the client.

F. Request a family member or friend to interpret information for the client.

G. Direct attention toward the interpreter when speaking to the client.

H. Review the facility policy about the use of an interpreter.

180. A nurse is caring for a client who is in labor and is receiving oxytocin. Which of

thefollowing findings indicates that the nurse should increase the rate of infusion?

ON THE REPORT needs double checking

A. Urine output 20 ml/hr.

D. Montevideo units constantly 300 mm Hg.

E. FHR pattern with absent variability.

F. Contractions every 5 min that last 30 seconds.

181. A nurse is planning care for a group of clients and is working with one licensed practical

nurse LPN and one assistive personal AP. Which of the following actions should the nurse

take first to manage her time effectively?

Develop an hourly time frame for tasks

Schedule daily activities

Determine goals of the day

Delegate tasks to the AP

182. A public health nurse is managing several projects for the community. Which of

the following interventions should the nurse identify as a primary prevention

strategy?

A. Teaching parenting skills to expectant mothers and their partners.

C. Conducting mental health screenings at the local community center.

C.Referring client who have obesity to community exercise programs.

D.Providing crisis intervention through a mobile counseling unit.

183. A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which

of the following statements by the client indicates an understanding of the teaching?

a. “I will take sucralfate with meals three times per day”

b. “I will avoid food and beverages that contain caffeine”

c. “I will decrease my daily protein intake to 15 grams per day”

d. “I will use ibuprofen as needed to control abdominal pain”

184. A nurse is assessing a client who is receiving packed RBCs. Which of the following

findings indicate fluid overload?

A.Low back pain.

Dyspnea.

Hypotension.

Thready pulse.

185. A nurse is providing teaching about patient-controlled analgesia (PCA) to a client.

Which of thefollowing statements should the nurse include in the teaching?

U. “The PCA will deliver a double dose of medication when you push the button twice.”

V. “You can adjust the amount of pain medication you receive by pushing on the keypad.”

W. “Continuous PCA infusion is designed to allow fluctuating plasma medication levels.”

X. “You should push the button before physical activity to allow maximum pain control.”

186. A nurse is preparing to administer an autologous blood product to a client.

Whichof the following actions should the nurse take to identify the client?

M.Match the client’s blood type with the type and cross match specimens.

N. Confirm the provider’s prescription matches the number on the blood component.

O. Ask the client to state the blood type and the date of their last blood donation.

P. Ensure that the client’s identification band matches the number on the blood unit.

187. A nurse is performing physical therapy for a client who has Parkinson’s disease. Which

of the following statements by the client indicates the need for a referral to physical

therapy?

E. “I noticed that I am having a harder time holding on to my toothbrush”

F. “Lately, I feel like my feet are freezing up, as they are stuck to the ground”

G. “Sometimes, I feel I am making a chewing motion when I’m not eating”

188. A nurse is reviewing laboratory data for a client who has chronic kidney disease.

Whichof the following findings should the nurse expect?

A.Increased creatine.

B. Increased

hemoglobin.

C.

Increased

bicarbonate.

D. Increased calcium.

189. A nurse is teaching at a community health fair about electrical fire prevention.

Which of thefollowing information should the nurse include in the teaching?

I. Use three pronged grounded plugs.

J. Cover extension cords with a rug.

K. Check the tingling sensations around the cord to ensure the electricity is working.

L. Remove the plug from the socket by pulling the cord.

190. A charge nurse is recommending postpartum client discharge following a local

disaster. Which of the following should the nurse recommend for discharge?

F. A 15-year-old client who delivered via emergency cesarean birth 1 day ago.

G. A client who received 2 units of packed RBCs 6 hr. ago for a postpartum hemorrhage.

H. A client who delivered precipitously 36 hr. ago and has a second-degree perineal laceration.

I. A 42 yoars old client who has preeclampsia and BP of 166/110 mmHG

191. A nurse is administering a scheduled medication to a client. The client reports that the

medication appears different than what they take at home. Which of the following

responses should the nurse take?

140 “I recommend that you take this medication as prescribed”

141 “Do you know why this medication is being prescribed to you?”

142 “I will call the pharmacist now to check on this medication”

Did the doctor discuss with you that there was a change in this medication

192. A community health nurse is developing a plan to improve the communitys environmental

health.which of the following action nurse take first?

Establish a timeframe for environmental improvements.

Encourage community Involvement in environmental improvement

Request funding from community organizations

Collect information about the community's environmental status

193. 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?

M. Withhold the next dose.

N. Increase the dosage.

O. Discontinue the medication.

P. Administer the medication.

194. A nurse in a clinic is assessing a 6-month-old infant. Which of the following should the

nursereport to the provider?

Pulse 140/min

Closed anterior

fontanelRespiratory rate

26/min Abdominal

breathing

195. A nurse is reviewing legal issues in health care with a group of newly licensed nurses. Which

ofthe following recommendations should the nurse make?

Place copies of incident reports in client’s medical records

Overestimate clients acuilty to prevent short staffing

Ensure that each client has a living will on file prior to treatment

Obtain personal professional liability insurance coverage

196. A nurse is planning care for a child who has neutropenia due to leukemia. Which of the

followingInterventions should the nurse Include in the plan of care?

Screen the child's visitors for active Infections.

Initiate Prepare the child for a platelet transfusion.

Prepare the child for a platelet transfusion.

Monitor the child for indications of active bleeding

197. A nurse is caring for a client who is near the end of life and is on complete bed rest. The

clientstates that he needs to have a bowel movement and the nurse offers a bed pan. 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 bed pan.”

“I will have the physical therapist ambulate you to the

bathroom.”“You have to use the bed pan for you own safety.”

“Make sure to use nearby furniture to support yourself when walking to the bathroom.

198. A newly licensed nurse is unsure if an assigned task is within their scope of practice. which

of thefollowing resources should the nurse consult?

Written prescription from the provider

Institutional policies and procedures

Verbal direction from the nurse

managerState Nurse Practice Act

199. A Nurse is teaching participants at a community center about advance directives. Which

of thefollowing information should the nurse include in the teaching?

Assigning a health care surrogate requires legal consultation

A client must create a do not resuscitate order when completing advances directives.

Advance directives cannot be changed once implemented.

A health care surrogate makes health care decisions when the client is no longer able.

200. 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

understandingof the teaching?

Q. “Staff will apply identification band after first bath”

R. “I will not publish public announcement about my baby’s birth”

S. “I can remove my baby’s identification band as long as she is in my room”

T. “I can leave my baby in my room while I walk in the hallway”

201. A nurse is planning care for four clients who are at risk for fluid imbalances. The nurse

shouldidentity that which of the following client for fluid volume excess?

A client who has ulcerative colitis

A client who has an exacerbation of peptic ulcer disease

A client who has diabetes insipidus

A client who has advanced stage liver cirrhosis

202. A nurse is caring for a client receiving mechanical ventilation via an endotracheal tube The

high pressure alarmis beeping and the.. experiencing respiratory distress. the nurse is unable

to determinethe cause pf the alarm. Which of the following actions should the nurse …

Deliver breaths manually with a resuscitation bag

Decrease the ventilation flow rate

Reevaluate the client for an ET cuff leak

Assess for disconnected tubing

203. A nurse on a mental health unit is admitting a client who has posttraumatic stress,

disorder.Which ofthe following should the nurse expect ?

Experiences frequent grandiose thoughts

Talks continuously about the event

has difficulty concentrating on a task

Preoccupled with having a serious illness

204. A nurse is verifying a record of informed consent for a client who is sheduled for surgery

.Which ofthe following actions should the nurse ….?

Inform the client about the condition that requires teatment

Confirm the client's signature Is authentic

Explain the procedure to the client before verifying informed

Provide Information on the informed consent form about the benefits of the surgery

205. A nurse in a mental health clinic receives a request from a client who is undergoing

psychotherapy to obtain a copy of the therapist’s notes. Which of the following responses

should the nurse make?

We can provide a copy of your records, but the therapists notes are not includedI

don’t think you will benefit from reviewing your therapists notes right now Why

are you interested in seeing your therapist’s notes?

Are you not happy with your treatment?

206. A nurse is screening food brought in by a family member for a client who takes phenelzine.

The nurse should instruct the family members…of the following foods can cause an interaction

with this medication ?

Cottage cheese

loeberg lettuce salad

bologna sandwich

Orange gelatin

207. A nurse is assessing a client who is in skeletal traction for a fractured left tibia.The nurse

shouldidentify that which of the following … altered tissue perfusion of the affected

extremity ?

Faint pedal pulse of left leg

Warm sidn temperature distal to pin site

Pain with movement of the left great toe

Purulent drainage at the pin site

208. A nurse is caring for a client who has bipolar disorder. Which of the following behaviors

should thenurse identify as indicating the client experiencing mania ?

Z.

The client speaks using echopraxia

The client speaks using word salad.

The client is easily distracted by external stimuli

The client is socially withdrawn

209. A nurse is obtaining a urine specimen from a client who has had an indwelling urinary

catheter forthree days. Which of the following action should the nurse take after collecting

the specimens?

Remove gloves after labeling the specimen

Place the specimen in a biohazard bag for transport

Obtain the specimen from the drainage collection

bag Wipe the outside of the specimen container with

alcohol

210. A nurse is caring for a toddler who has acute lymphocytic leukemia. In

whichof the following should the toddler participate?

Y. Looking at alphabet flashcards.

Playing with a large plastic truck.

AA.Use scissors cut out paper shapes.

BB. Watching a cartoon in the dayroom.

211. A nurse is reviewing the cardiac rhythm of a client who is ….. on indication

ventriculartachycardia?

P wave present with every QRS

complexSowtooth shaped P waves

PR interval of 0.24 seconds

QRS complexes wider than 0.15 seconds

212. A nurse is admitting an older adult client who is transferring from another facility. The

nurse notes pressure ulcers on the client’s coccyx and abrasions around the wrists.

Which of the following actions should the nurse take to address the suspicions of elder

abuse?

Inform the transferring agency of the client’s condition.

Privately interview the client about her condition.

Notify risk management

Contact the family regarding the client’s condition.

213. community health nurse is reviewing laboratory reports for a group of client. The nurse

shouldidentify that which of the following disorder on the CDC's Nationally Notifiable

Conditions list!Bacterial vaginosis

Lyme disease

Respiratory syncytial

virusPediculosis capitis

214. A nurse is teaching a client who is trying to conceive. Which of the following should the

nurse instruct in her diet to prevent a neural tube defect?

Folate

Zinc

Iron

Calciu

m

215. A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl. Which

of thefollowing manifestations should the nurse expect?

Loose stools

Jitteriness Hypertonia

Abdominal distention

216. A Nurse is preparing to administer PRN pain medication to a client who has cholelithiasis

and experiencing moderate abdominal pain. Which of the following medications should the

nurse plan toadminister?

Omeprazole

Ketorolac

Acetaminophe

n

Metoclopramid

e

217. A nurse is giving an intramuscular injection to a newborn who has delivered at 38

weeks of gestation .Which of the following pain scale should the nurse use to assess the

newborn pain ?FACE pain rating scale

Premature Infant Pain Profile

(PIPP)Visual analog scale (VAS)

Neonatal Infant Pain Scale (NIPS)

218. A nurse is admitting a client who does notspeak the same language asthe nurse and scheduled

foroutpatient surgery. Which of following actions should the nurse take?

Request a family member to interpret the information.

Explain the procedure to the client through an

interpreter.

Provide consent form that is written in the client’s own language.

Help the client look up the information about the procedure on the internet

219. A nurse is preparing to initiate IV therapy for an older adult client. Which of the following

actionsshould the nurse plan to take ?

Clean the site using vigorous friction

Apply a tourniquet firmly above the

insertion Use 22-gauge catheter for

insertion

Select a vein on the back of the hand

220. A nurse is caring for a client who has fibromyalgia and requests pain medication.

Which ofthe following medications should the nurse administer?

Pregabalin

Lorazepam

Colchicine

Codeine

221. A nurse is providing discharge teaching for a group of clients. The nurse should

recommend areferral to a dietitian

E. A client who has a prescription for warfarin and states “I will need to limit how muchspinach

I eat”.

A client who has gout and states, “I can continue to eat anchovies on my pizza.”

G. A client who has a prescription for spironolactone and states “I will reduce my intake offoods

that contain potassium”.

H. A client who has (Unable to read) and states “I’ll plan to take my calcium carbonate witha

full glass of water”.

222. A nurse is reviewing the medical record of a client who has a prescription for

intermittent heat therapy for a foot injury. Which if the following findings should the

nurse identify as a contraindication for heat therapy?

Phlebitis

Abdominal aortic aneurysm

Osteoarthritis

Peripheral neuropathy

223. 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 infection?

Clean blood contaminated surfaces with

bleach.Use condoms with a petroleum-based

lubricant.Wash soiled clothes in cold water.

Buy disposable dishes for daily use.

224. A nurse is caring for a client who is receiving continuous enteral feedings. which of the

followingactions should the nurse take? Select

Check placement of the feeding tube by x-ray once daily

Maintain the head of the client's bed at a30% angle or

higherCheck gastric residuals every 4 hr.

Change the feeding container and tubing every 24

hr. Ensure the formula is cold before

administration

225. A nurse is assessing a client who has bipolar disorder and is experiencing depressive

episode.which of the following findings should the nurse expect?

Clent expresses ilusions of grandeur

Inability to carry out a simple task

Client reports auditory hallucinations

Moves quickly from one idea to the

next

226. A nurse is caring for a client who is postoperative immediately following a cardiac

catheterizacionwith a right femoral appro..Which of the following actions should the nurse

F.

take?

Elevate the head of the client's bed to 45

Assess the client's peripheral pulses every 15 min.

Change the client's dressing 4 hr following the

procedure.Instruct the client to flex the right knee

every 30 min.

227. A nurse is teaching a client who has chronic low back pain about the use of alternative

therapy tomanage pain. Which of the following by the client indicates an understanding of

the use of distraction?

I will have electrodes inserted in my skin to treat the pain

I should apply my heating blanket to my back to reduce tension

I should jog every morning to improve my circulation

I will watch my favorite old movies when I want to reduce stress

228. A nurse is providing dietary teaching to a client who has hyperlipidemia .The nurse should

includein the teaching that which obtains she lowest amount of saturated fats ?

Coconut

oil Olive

oil Canola

oil Palm

oil

229. A nurse is reviewing assessment data from several clients. For which of the following

clients should the nurse referral to a dietitian?

An older adult client who has a BMI of 24

A client who has a nonhealing leg ulcer An

older adult client who has presbyopia

A client who has an albumin level of 3.7g/Dl

230. A nurse is teaching a childbirth education class and is discussing sexual intercourse

duringpregnancy. Which of the following statements should the nurse make?

“The female superior position can be used during the third trimester of pregnancy.”

“Frequent intercourse increases the risk for miscarriage in early pregnancy.”

“You should limit the frequency of intercourse after weeks of

pregnancy.”Your sexual desire might increase during the first trimester

of pregnancy.”

231. A nurse is caring for an older adult client in a long-term care facility, recently lab values

showsincreased hemoglobin, hematocrit, and urine irregularity which findings suggest

anemia

Anemia.

Dehydration

Hepatic failure

Acute renal

failure

232. 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?

Take a bubble bath after

intercourseVoid every 5 to 6 hr

during the day

Drink four 240 mL (8 oz) glasses of water each day.

Wear loose-fitting underwear.

233. 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 totake? (Select all that apply.)

Caution staff that the equipment is complicated to use.

Wait to offer feedback on staff use of the equipment until the end of the session.

Identify the current level of staff knowledge about the equipment.

234. A nurse is providing teaching to a client who is experiencing preterm

contractionsand dehydration. Which of the following statements should the nurse

make?

K. “Dehydration is treated with calcium supplements”

L. “Dehydration can increase the risk of preterm labor”

M.“Dehydration associated gastroesophageal reflux

N. “Dehydration is caused by a decreased hemoglobin and hematocrit”

235. A nurse is preparing a change of shift report for an adult female client who is

postoperative. Which of the following client information should the nurse include in the

report?

CONFIRMED

Hgb 12.8 g/dl - 12- 16

Potassium 4.2 meq/l 3.5 - 5.0 meq

RBC 4.4 million/mm3

Platelets 100,000/mm3

236. A nurse is caring for a client who tells the nurse that he feels he is being discharged

from thefacility too soon .which of the following the nurse demonstrate client advocacy?

I will contact your insurance company to see if they will pay for you to be have

longer?Your provider understands your illness and is acting according to your best

interests

I will that the provider about your concerns

I know you will be able to recover faster at home

237. A nurse is teaching a group of clients who are planning to have bariatric surgery. Which of

the following statements by a client indicated an understanding of the teaching?

“I will consume 48 ounces of carbonated beverages daily prior to the

surgery.”“I will need to lose 25 percent of my excess body weight prior to

surgery.”

“I should reduce my daily caloric intake by 250 calories to lose 2 pounds each week after

Require a return demonstration using the equipment.

Provide reinforcement of teaching until the skill islearned.

surgery.”“I should wait 30 minutes after eating solid foods to drink beverages following

surgery.”

238. A nurse is caring for several clients on a medical-surgical unit. For which of the

followingnursing activities is it required that the nurse use sterile gloves?

Inserting an NG tube

Administering total parenteral nutritional through a central venous access device

Initiating IV access

Performing tracheostomy care

239. A nurse in a surgical clinic is providing teaching to a client who is scheduled for a modified

radical mastectomy. Which of the following statements by the client indicates an understanding

of the teaching?

“I can begin to drive 24 hours after

surgery.” “I can shower within 48 hours of

my surgery.”

“I will have my drains removed 1 hour prior to going

home.”‘I will complete my arm exercises four times a

day.”

240. A nurse is teaching a client who has systemic lupus erythematosus (SLE). Which of the

following statements by the client indicates an understanding of the teaching?

“I should apply power to my skin after

showering.”“I will not able to go for my daily

walk.”

“I will cleanse my skin using a mild soap.”

“I should check my skin once weekly for rashes.”

241. A nurse is providing discharge teaching to a female client who has tuberculosis and

a newprescription for rifampin. Which of the following information should the nurse

include?

“Your urine will be orange while this medication.”

Weight gain is an expected adverse effect of this medication

You should avoid getting pregnant for 6 months after stooping this

medicationYou should avoid sun exposure while taking this medication

242. A nurse is providing discharge Instructions to a client who has a new

prescription forspironolactone .Which of the following the nurse include in the

teaching?

Monitor weight once a week

Take the medication in the

morningUse a salt substitute with

meals

Administer a potassium supplement daily

243. A nurse is caring for a client who has acute exacerbation of multiple sclerosis. Which

of thefollowing prescriptions should the nurse expect the provider to prescribe?

Atorvastatin

Amoxicillin

Enoxaparin

Interferon beta1a

244. A nurse is caring for a client who has a history of depression and is experiencing a

situational crisis. Which of the following actions should the nurse take first?

A. Confirm the client’s perception of the event

B. Notify the client’s support system

C. Help the client identify personal strengths

D. Teach the client relaxation techniques

245. A nurse is counseling a group of clientsfrom 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 posttraumatic 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 expresses a realization that life will not return to the way it was before the

hurricane.A client who moved to an apartment located on higher ground than her previous

home.

A client who describes feeling disconnected from those around him following the hurricane.

246. A nurse is caring for a client who has cancer of the throat and is receiving radiation

therapy. Thenurse should monitor for which of the following finding as an adverse effect of

the radiation?

Excessive

salivation

Insomnia

Altered sensation

Elevate platelet

count

247. A nurse is providing teaching to a client who is breastfeeding and experiencing

engorgement.Which of the following recommendations should the nurse include?

Wear a tight-fitting underwire bra.

Apply warm compresses on the breasts before

feedings.Allow the infant to nurse on one breast per

feeding.

Take aspirin to reduce pain and swelling.

248. A nurse is a community clinic is caring for client who request assistant with smoking

censation Thenurse should expect a prescription for which of the following medications?

Bupropion

Chiordiazepoxi

de Naltrexone

Clonidine

249. A nurse is preparing to administer an IV medication to a client and accidently

punctures the IV bag causing the medication to leak on the counter. Which of the

following medications requires the nurse to follow facility procedures in the safe handling

of biohazardous material spill?

Doxorubicin hydrochloride

Ampicillin sodium

Metronidazole

Phenytoin

132. 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.Assess

the newborn pain level using 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.

133. 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 SQ every 4 hr. PRN for pain.”

“Morphine 3 mg Subcutaneous every 4 hr PRN for pain

“Morphine 3.0 mg sub q every 4 hr. PRN for pain.”

“Morphine 3 mg SC q 4 hr. PRN for pain.”

134. A nurse is caring for a client who has gestational hypertension and is experiencing toxic effects

due tomagnesium sulfate therapy. The nurse should anticipate administering which of the

medications?

Calcium gluconate

Sodium

bicarbonate.

Potassium

chloride.

Magnesium citrate

135. A nurse is reviewing the formulary about NPH insulin before administering the medication to

a client.Which of the following information the nurse expect ?

Administrer NPH Insulin 30min before

breakfast.Give NPH Insulin by IV bolus

Use NPH insulin to treat ketoacidosis

Discard the NPH insulin vial if the medication is cloudy

136. A nurse is planning care for a school age child who is 4 hr postoperative following appendicitis

.Which ofthe following action should the nurse include in the plan of care ?

Administer analgesics on a scheduled basis for the first

24 hrApply a warm compress to the operative site once

daily Offer small amounts of dear liquids 6 hr following

surgery Give cromolyn nebulized solution every8 hr

137. A nurse is preparing to admit a client who is 35 weeks of gestation for evaluation of the fetal

well beingdue to potencial preterm labor following places of equipment should the nurse use to

evaluate the fetal heart rate?

Intrauterine pressure

catheterSpiral electrode

Toco transducer

ultrasound

transducer

138. A nurse isreviewing the medical record of a client who has delayed healing of a leg ulcer. Which

of thefollowing findings should the nurse identify as a contributing factor?

The client takes prednisone for arthritis.

The client is receiving IV dextrose 5% in water at 100

mL/hr. The client has a total cholesterol level of 190

mg/dL.

The client has an albumin level of 3.8 g/dL

139. A nurse is caring for a client who has hypertension and a new prescription for chlorthalidone. The

nurseshould monitor for which of the following adverse effects?

Hypoglycem

ia

Hypokalemi

a Euphoria

Increased intraocular pressure

140. A nurse is providing discharge instructions about newborn safety to a client who is 2 days

postpartum.Which of the following instructions should the nurse include?

Change smoke detector batteries every other year.

Lay the baby on his stomach to nap during the

daytime.Use a car seat when traveling by airplane

Place a plastic waterproof sheet over the crib bedding.

141. A nurse is caring for a client who is 12 hr postoperative following aortofemoral bypass surgery

.which ofthe following finding should the nurse impact in the affected extremity?

Cool

extremities

Pedal pulse of

2+ Throbbing

pain

Capillary refill of 4 seconds

142. A home health nurse is teaching a new parent about caring for his 1-week-old-infant. Which

of thefollowing statements by the client indicates an understanding of the teaching?

“I can use a form pillow to prop up the bottle when feeding my

baby.”“I will avoid picking up my baby too often to keep from

spoiling him.” “I will hang a pastel-colored mobile 24 inches

above my baby’s crib.”

“I will place a ticking clock nearly to soothe my baby throughout the day.”

143. 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.

Wipe urine from the skin using a cool cloth

Apply talcum powder to the irritable area

144. A nurse is assessing a client who is receiving daily aspirin therapy .The nurse should identify that

which ofthe following allergic reaction to this medication ?

Difficulty

swallowing Blurred

vision

Weight gain

High blood pressure

145. A nurse is preparing to measure a temperature of an infant. Which of the following

action shouldthe 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 (1.5in)into the infant’srectum.Insert

the thermometer in front of the infant’s tongue.

146. A nurse is caring for a client who has chronic pancreatitis. Which of the following

dietaryrecommendations should the nurse make?

CC. Coffee with creamer.

DD.Lettuce with sliced avocados.

EE. Broiled skinless chicken breast with brown rice.

FF. Warm toast with margarine.

147. A nurse in a provider’s office is reviewing a female client’s medical record during a routine

visit. The nurse should recommend increasing dietary intake of which of the following

vitamins? (Exhibit) --only tab shown is Tab 3:

a. Vitamin D

b. Vitamin K

c. Vitamin A

d. Vitamin B12

148. A nurse is assessing a client who is 30 min postoperative following an arterial

thrombectomy. Which of the following findings should the nurse to report?

Chest pain

Muscle spasms.

Cool, moistskin.

Incisional pain.

149. A nurse is providing teaching to a client who isto begin external radiation therapy for cancer .Which

of thefollowing information include ?

Wash your skin thoroughly with a washcloth after each

treatmentWear a binder over the radiation site

You might experience altered taste

sensations Use rubbing alcohol to remove the

ink maricings

150. A nurse is caring for an infant who has respiratory svncytial virus . Which of the following

interventionshould the nurse take ?

Suction nares prior to feeding

Request a prescription for

guaifenesin

Administer palivizumab

intravenously Initiate neutropenic

precautions

151. 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 thefollowing by the nurse is therapeutic?

“Can you talk about what happens with your partner at home?”

“Why do you think your partner’s symptoms are progressing so quickly?”

“You should make sure your partner takes the prescribed medication.”

“You did the right thing by bringing your partner in for treatment.”

152. A nurse in a provider’s office is reviewing the laboratory results of a group of clients. The

nurse should identify that which of the following sexually transmitted infections is a

nationally notifiable infectious disease that should be reported to the state health

department?

E. Chlamydia

F. Human papillomavirus

G. Candidiasis

H. Herps simplex virus

153. 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’s parent is in a skilled nursing facility

The client is allergic to penicillin

The client has two small children at home

The client lives in a two-story home

154. A nurse is caring for a client who has heart failure. The nurse notes the client’s 24-hr-intake is

1.750 mLand output is 425 mL. Which of the following actions should the nurse take first?

Compare the client’s wight to the previous

day.Reduce the client’s sodium intake.

Encourage the client to change positions

frequently.Administer furosemide to the client.

155. A nurse in a mental health facility receives change-of-shift report for four clients. Which of the

followingclients should the nurse plan to assess first?

A newly admitted client who has a hx of 4.5 kg (10lb) weight loss in the past 2 months

A client who will be receiving her first ECT treatment today

A client placed in restraints due to aggressive behavior

A client who received a PRN dose of haloperidol 2 hr ago for increased anxiety

156. A nurse is caring for a newborn who is experiencing neonatal abstinence syndrome. which

of thefollowing actions should the nurse take

Decrense the lighting levels in the

nurseryWrap the newborn loosely in a

bianket

Encourase frequent eye contact with the newborn during

feedingProvide frequent stimulation for the newborn

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