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ATI Exit Exam - 180 Questions and Answers EXIT EXAM 1. A nurse is caring for a client who has given informed consent for ECT. Just before the procedure, the client tells the nurse she is considering not going for ...

ATI Exit Exam - 180 Questions and Answers EXIT EXAM 1. A nurse is caring for a client who has given informed consent for ECT. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate? a. “You don’t have to go through with the treatment.” b. “Most people who have this procedure feel better following the treatment.” c. “It’s okay to be nervous before this treatment.” d. “Your doctor wouldn’t have ordered this treatment unless it was necessary.” 2. While performing a routine assessment, a nurse notices fraying on the electrical cord of a client’s CPM device. Which of the following actions should the nurse take first? a. Report the defect to the equipment maintenance staff. b. Ensure the device inspection sticker is current c. Remove the device from the room d. Initiate a requisition for a replacement CPM device 3. A nurse is caring for a client who is postoperative and has a new prescription for hydromorphone. Which of the following actions should the nurse take? a. Document administration of the medication upon removal from the medication dispensing system b. Withhold the medication if the client does not appear to be in pain. c. Count the current number of unit doses available in the medication dispensing system d. Withhold the medication if the client has a fever 4. A nurse performing a change-of-shift assessment. Which of the following clients has the priority finding? a. Type 2 DM and a blood glucose of 250 mg/dL b. Pneumonia with a productive cough and a fever of 38.8° C (101.8° F) c. 2 hr. post cast placement and has 2+ pitting edema and pallor d. First-degree heart block and a heart rate of 62/min 5. A nurse in an outpatient mental health facility is providing teaching to a group of adolescents. Which of the following statements by a client indicates an understanding of the teaching? a. “I will limit my alcohol use to one drink daily while taking disulfiram.” b. “I will avoid foods containing tyramine while taking fluoexetine.” c. “I will take the sustained-release methylphenidate every morning.” d. “I will take my lithium on an empty stomach.” (pharm pg. 64: taking lithium with food will help decrease GI distress) 6. A nurse in the emergency department is assessing client who has major depressive disorder. Which of the following actions should the nurse take first? [View Exhibit] a. Administer Zofran to the client for nausea b. Implement seizure precautions for the client c. Encourage the client to verbalize feelings d. Obtain the client’s weight 7. A nurse is completing an admission assessment for a client who ahs narcissistic personality disorder. Which of the following should the nurse expect? a. Suspicious of others b. Exhibits separation anxiety c. Ritualistic behavior d. Preoccupied with aging 8. Drug Calc: Client weighs 99 lb. Prescribed diet of 1.5 g protein/kg/day. How many grams of protein per day should the nurse include in the client’s dietary plan? 9. A nurse is planning care for a group of clients and is working with one LPN and one AP. Which of the following actions should the nurse take first to manage her time effectively? a. Develop an hourly time frame for tasks b. Schedule daily activities c. Determine goals of the day d. Delegate tasks to the AP 10. A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? a. Restrict the client’s total fluid intake to 250 mL/hr. b. Measure the client’s urine output every hour c. Give the client protamine if signs of magnesium sulfate toxicity occur (antidote: calcium gluconate) d. Monitor the FHR via Doppler every 30 min 11. A nurse is caring for a group of clients. Which of the following wounds should the nurse expect to heal by primary intention? a. Infected laceration b. Stage II pressure ulcer c. Approximated surgical incision d. Partial-thickness burn 12. A nurse in an acute mental health care facility is prioritizing care for multiple clients. Which of the following clients should the nurse see first? a. Client taking clozapine to treat schizophrenia and reports sore throat (pharm pg. 72: monitor for infection [fever, sore throat, etc.]) b. Client has OCD and is upset about a change in daily routine c. Client has narcissistic personality disorder and is mocking others during group therapy d. Client who has depressive disorder and requires assistance with ADLs 13. A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to assess the port? a. An angiocatheter b. A butterfly needle c. A noncoring needle d. A 25 gauge needle 14. A nurse is caring for a client who has pneumonia and tells the nurse, “I feel like an elephant is sitting on my chest.” The client is weak and unable to walk. After the nurse indicates chest pain protocol, which of the following is the priority diagnostic test? a. PT and INR b. 12 lead ECG c. Chest X-ray d. Serum potassium 15. A nurse is assessing the growth and development of a 3 y/o child. Which of the following questions should the nurse ask the parent to determine if the child is exhibiting typical developmental expectations? a. “Can your child draw a stick figure?” b. “Can your child catch and throw a small ball?” c. “Can your child ride a tricycle?” d. “Can your child name five colors?” 16. A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take? a. Measure the fundal height to determine the placement of the ultrasound stethoscope b. Perform Leopold maneuvers prior to auscultating the FHR c. Position the ultrasound stethoscope above the symphysis pubis to assess the FHR d. Place the client in a side-lying position prior to assessing the FHR 17. A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon assessment, the nurse notes tidaling in the water seal. Which of the following is an explanation for the tidaling? a. There is a loop of tubing below the drainage system b. The system is working properly (medsurg pg. 104: tidaling in the water seal chamber and continuous bubbling only in the suction chamber) c. The lung has re-expanded d. The tubing is partially obstructed by clots 18. A charge nurse on a medical surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? a. A client who is receiving heparin for DVT b. A client who is 1 day postoperative following a vertebroplasty c. A client who has COPD and a respiratory rate of 44/min d. A client who has cancer with a sealed implant for radiation therapy 19. A nurse is caring for a client who has ESRD. The client’s adult child asks the nurse about becoming a living kidney donor for her father. Which of the following conditions in the child’s medical history should the nurse identify as a contraindication to the procedure? a. Osteoarthritis b. HTN c. Amputation d. Primary glaucoma 20. A nurse is caring for a client who is 4 days postpartum. Which of the following assessment findings should the nurse expect? (SATA) a. Foul perineal odor b. Fundus displaced to the right c. Lochia serosa d. Fundus 4 cm (1.6 in) below the umbilicus e. Postpartum chill 21. A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? a. Perform the procedure twice a day b. Hold hand to perform percussions on the child c. Administer a bronchodilator after the procedure d. Perform the procedure prior to meals 22. A home care nurse is making a follow up visit with a client who has COPD and is using a compressed oxygen system in his home. Which of the following action should the nurse take? a. Ensure that the client checks the gauge weekly b. Store the oxygen tank wrench in a locked cabinet c. Have the client store smaller tanks under his bed d. Place the oxygen tank away from curtains or drapes 23. Location of crackles [IMAGE] 24. A nurse is caring for a newly client who has bacterial meningitis. Which of the following actions should the nurse take? (medsurg pg. 31) a. Implement seizure precautions b. Place the client in high-Fowler’s position c. Perform ROM exercises once per shift d. Monitor the client for hypoglycemia 25. A nurse is reviewing the preadmission lab tests results of a client who is to undergo hip arthroplasty in 2 days. Which of the following results should the nurse report to the provider? a. Na 142 mEq/L b. Blood glucose 80 mg/dL c. K 3.3 mEq/L d. PT 11.5 seconds 26. A nurse is caring for a client who has undergone a modified radical mastectomy. The client has a closed-suction drain. Which of the following actions should the nurse take? a. Reset the vacuum by compressing the container b. Secure the drain to the bedding c. Position the affected extremity below the level of the client’s heart d. Maintain the client in a supine position for the first 24 hr. 27. A nurse is receiving change of shift report for four clients. Which of the following clients should the nurse assess first? a. DM and HbA1c of 5.2% b. Leukemia and platelet level of 95,000/mm3 c. Received IV Lasix and K of 3.6 mEq/L d. Hepatitis B and total bilirubin of 1.2 mg/dL 28. A nurse is developing plan of care for a newborn mother tested positive for heroin during pregnancy. Newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan? a. Minimize noise in the newborn’s environment b. Swaddle the newborn with his legs extended c. Administer naloxone to the newborn d. Maintain eye contact with the newborn during feedings 29. Nutritional teaching for an adult client who has seizure disorder and a new prescription for phenytoin. Which of the following instructions by the nurse is appropriate? a. “You should expect a change in the color of your stool while taking this medication.” b. “Increase your intake of vitamin D while taking this medication.” (pharm pg. 96: consume adequate amounts of calcium and vitamin D) c. “Plan to take this medication with antacids.” d. “Limit foods that contain folic acid while taking this medication.” 30. A nurse is assessing a client who presents to the L&D unit reporting the onset of contractions. Which of the following findings should the nurse identify as a manifestation of false labor? a. Presence of bloody show b. Contraction intensity increased by ambulation c. Slow change in dilation and effacement d. Intermittent, painless contractions 31. A nurse is caring for a client who has Cdif. Which of the following actions should the nurse take? (SATA) a. Wash hands with alcohol based b. Wear N95 c. Remove thermometer from client’s room for use on another client d. Change gloves after contact with infectious material e. Wear a gown when providing care 32. A nurse is receiving change of shift report for a group of clients. Which of the following clients should the nurse plan to assess first? a. DM and HbA1C of 6.8% b. Hip fracture and a new onset of tachypnea c. Epidural analgesia and weakness in lower extremities d. Sinus arrhythmia and is receiving cardiac monitoring 33. Nurse accidently punctures IV bag causing the medication to leak on the counter. Which of the following medications requires the nurse to follow facility procedures in the safe handling of a bio hazardous material spill? a. Phenytoin b. Doxorubicin hydrochloride c. Metronidazole d. Ampicillin sodium 34. Postoperative client following appendectomy and receiving gentamicin. Which is an adverse effect of this medication? a. Respiratory rate 22/min b. Hgb 8.7 g/dL c. 2+ pitting edema of the ankles d. Creatinine 2.3 mg/dL (pharm pg. 365: nephrotoxicity) 35. Which of the following clients should the nurse recommend referral to a dietitian? a. Older adult who has BMI of 24 b. Client with albumin of 3.7 g/dL c. Older adult who has presbyopia d. Client who has a nonhealing leg ulcer 36. Support group for clients whose family have committed suicide. Which of the following should the nurse plan to use during the group session? a. Encourage clients to establish a timeline for their grieving process b. Assist clients in identifying ways suicide could have been prevented c. Discourage clients from sharing negative aspects of their relationship with the deceased persons d. Initiate a discussion with clients about ways to cope with changes in family dynamics 37. Which of the following risk factors should the nurse include as the best predictor of future violence? a. Experiencing delusions b. A history of being in prison c. Male gender d. Previous violent behavior 38. Arial fibrillation places the client at risk for which of the following conditions? a. Pulmonary emboli b. Cardiac tamponade c. Widened pulse pressure d. Hemothorax 39. Client with schizophrenia and experiences auditory hallucinations. Which actions should the nurse include in the plan? a. Refer to the hallucinations as if they are real b. Encourage the client to lie down in a quiet room c. Ask the client directly what he is hearing d. Avoid eye contact with the client 40. Circumcised newborn. Which of the following instructions should the nurse include in the teaching? a. “Wrap sterile gauze around the penis if bleeding occurs.” b. “Use soap to cleanse the site.” c. “Apply petroleum jelly to the glans with diaper changes.” d. “Remove yellow exudate around the penis.” 41. Crohn’s disease. Which of the following diagnostic procedures should the nurse plan to teach the client regarding pernicious anemia? a. Schilling test (medsurg pg. 254) b. Oral glucose tolerance test c. D-dimer test d. Thyroid scan 42. A nurse is creating a care plan for a client who is postoperative following a CABG. To prevent complications of cardiac surgery, which of the following instructions should the nurse include in the plan of care? a. Administer atropine to the client if tachycardia is present b. Maintain the indwelling urinary catheter until the client is ready for discharge c. Prepare for fluid volume replacement if the central venous pressure steadily increases d. Check the client’s hemoglobin level if chest tube drainage is 300 mL in the first 1 hr (medsurg pg. 185: volume exceeding 150 mL/hr could be a sign of hemorrhage) 43. A nurse is reviewing the medication administration record of a client who has rheumatoid arthritis and is 1 day postoperative following a left total hip arthroplasty. Which of the following medications places the client at risk for delayed wound healing? a. Morphine b. Digoxin c. Prednisone d. Omeprazole 44. Client becomes unconscious and monitor displays v-tach. Which action should the nurse take first after determining the client does not have a palpable pulse? a. Establish IV access b. Administer epinephrine c. Defibrillate d. Assess heart sounds 45. A nurse is caring for several clients on a med surg unit. For which of the following nursing activities is it required that the nurse use sterile gloves? a. Initiating IV assess b. Performing tracheostomy care c. Inserting an NG tube d. Administering total parenteral nutrition through a central venous assess device 46. Lab results s/p surgery. Which should be reported to the provider? a. Na 160 mEq/L b. Cl 100 mEq/L c. Bicarbonate 26 mEq/L d. K 3.8 mEq/L 47. Nurse is developing care plan for client on Buck’s traction and is schedules for surgery for a fractured femur of the right leg. Which should the nurse delegate to an AP? a. Observe the position of the suspended weight b. Remind the client to use the incentive spirometer c. Check the client’s pedal pulse on the right leg d. Ask client to describe her pain 48. Client in ER experiencing stimulant withdrawal. Which finding should the nurse expect? a. Decreased appetite b. Runny nose c. Muscle spasms d. Fatigue 49. Postpartum client with a language barrier. Which of the following actions should the nurse take to gather the client’s admission data? a. Allow client’s partner to translate b. Request female interpreter through the facility c. Have client’s child translate d. Ask nursing student who speaks the same language as the client to translate 50. Operating fire extinguisher [arrange] 1) Unlock the handle by pulling on the pin 2) Point the hose at the base of the fire 3) Squeeze the handle by pulling on the pin 4) Sweep the extinguisher from side to side 51. A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy obtain a copy of the therapist’s notes. Which of the following responses should the nurse make? a. “Are you not happy with your treatment?” b. “Why are you interested in seeing your therapist’s notes?” c. “I don’t think you will benefit from reviewing your therapist’s notes right now.” d. “We can provide a copy of your records, but the therapist’s notes are not included.” 52. A nurse is assessing a client who has hypervolemia. Which of the findings should the nurse expect? a. Urinary frequency b. Decreased BP c. Bounding pulse (medsurg pg. 267) d. Bradycardia 53. Inserting indwelling urinary catheter to a male client. Which of the following actions should the nurse take? a. Cleanse the tip of the penis in a side to side motion b. Pick up the catheter 13 cm (5 in) from its tip c. Perform the cleansing procedure with a fresh swab two times d. Lift the penis so that it is perpendicular to the client’s body 54. A nurse is caring for a client who is febrile. To reduce fever, the nurse applies a cooling blanket. Which of the findings indicates the client is having an adverse reaction to the cooling? a. Tachycardia b. Flushing c. Shivering d. Restlessness 55. Teaching for misoprostol. Which information should be included in the teaching? a. “You will have a urinary catheter inserted prior to the placement of the medication.” b. “You will lie on your side for 30 min after the medication is inserted.” c. “You will have oxytocin initiated within 3 hours of administration of the medication.” d. “You will have intermittent fetal monitoring while you receive the medication.” 56. Client in psychiatric unit. The client states, “The voices are telling me to jump.” Which of the following is an appropriate response by the nurse? a. “That can’t be true. The only voices in this room are yours and mine.” b. “You shouldn’t be afraid when you think the voices are telling you to hurt yourself.” c. “I understand the voices are frightening you, but I do not hear any voices.” d. “Do you recognize the voices as belonging to anyone you know?” 57. Teaching the parent of an infant who has positional plagiocephaly. Which of the following statements by the parent indicates an understanding of the teaching? a. “I should place my baby in the left side-lying position at night when using the helmet.” b. “I should avoid tummy time when my baby is wearing the helmet.” c. “I should expect to have my baby wear this helmet for 10 months.” d. “I should keep the helmet on my baby for 23 hours a day.” 58. Which of the following lab findings should the nurse recognize as indicative of rheumatic fever? a. Decreased hgb and platelet count b. Decreased myoglobin and antinuclear antibody titer c. Elevated sedimentation rate and C-reactive protein d. Elevated creatine kinase and troponin 59. Client with pneumonia gained 4.2 (9.3 lb.) over the last 5 days. Lab values this morning are: WBC 10,000/mm3, RBC 5.2 million/mm3, platelets 250,000/mm3, BUN 32 mg/dL, and serum creatinine 2.1 mg/dL. The nurse should report these findings to which of the following members of the interdisciplinary team? a. Nephrologist b. Cardiologist c. Infectious control nurse d. Dietitian 60. A nurse received change of shift report. Which of the following actions should the nurse take to manage time effectively? a. Focus on several client tasks at a time b. Document client care at the end of the shift c. Skip breaks until client tasks are completed d. Make a client to-do list for the day 61. Protocols for belt restraints. Which of the following guidelines should the nurse include? a. Remove the client’s restraint every 4 hr. b. Request a PRN restraint prescription for clients who are aggressive c. Attach the restraint to the bed’s side rails d. Document the client’s condition every 15 min 62. Assessing client in ER. Which of the following actions should the nurse take first? [View Exhibit] a. Obtain ABG levels b. Elevate the head of the client’s bed to 30° c. Place client on a coating blanket d. Administer an analgesic 63. Client who has depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicators an understanding of the teaching? a. “I can continue to take St. John’s wort while taking this medication.” b. “I know it will be a couple of weeks before the medication helps me feel better.” (pharm pg. 56: it can take 10-14 days or longer) c. “I expect this medication to raise my blood pressure.” d. “I should take this medication on an empty stomach.” 64. A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take? a. Instruct the client to lift her chin when swallowing b. Sit at or below the client’s eye level during feedings c. Talk with the client during her feeding d. Discourage the client from coughing during feedings 65. Child with sickle cell anemia. The nurse should emphasize the importance of which of the following factors to prevent sickle cell crisis? a. A low-protein diet b. Adequate hydration c. Calorie restriction d. Increased iron intake 66. Client with indwelling urinary catheter. Which of the following actions should the nurse take to provide catheter care? a. Provide perineal hygiene after defecation b. Empty the collected urine once every 24 hr. c. Hang the drainage bag on a bed rail d. Change the indwelling catheter every 8 hr. 67. Client experiencing acute mania. Which of the foods should the nurse provide for this client? a. Peanut butter sandwich b. Chicken noodle soup c. Celery sticks d. Oatmeal with butter 68. ?????????? 69. A home health nurse is completing screenings for elder abuse during client visits. Which of the following findings should the nurse identify as an indication of potential elder abuse? a. Client who reports being given sedative medications by family members b. Client who is taking warfarin and has several small bruises on her shins and hands c. Client who schedules multiple visits with his provider every month d. Client who lives with family members and begins to take more responsibility for self-care 70. A nurse is caring for a school age child who is postoperative and received morphine IV bolus for pain 10 min ago. Which of the following findings is the nurse’s priority? a. Bradypnea b. Sedation c. Euphoria d. Constipation 71. A nurse is planning to administer 2 units of packed RBCs to an older adult who has anemia. Which of the following actions should the nurse plan to take? [SATA] (medsurg pg. 249) a. Prime the infusion tubing with 0.45 NaCl b. Infuse blood over 4 hr. c. Don sterile gloves to prepare blood administration setup d. Assess the client’s lung sounds prior to the infusion e. Verify with another nurse that the unit of blood is compatible with the client’s blood type 72. A nurse is planning care for a client who is scheduled to receive a PICC in the arm. Which of the following interventions is appropriate for the nurse to include in the plan of care? (medsurg pg. 166) a. Administer sedation for the procedure b. Measure the arm circumference above the insertion site daily c. Use gauze to secure an arm board to the involved extremity d. Schedule and MRI postprocedure to verify placement 73. Which of the following clients should the nurse place near the nurses’ station? a. A client who is in Buck’s traction b. A client who has orthostatic hypotension c. A client who has an open wound d. A client who is on fluid restriction 74. Older client transferred from another facility. Nurse notes ulcers on the coccyx and abrasions around both wrists. Which of the following actions should the nurse take to address suspicions of elder abuse? a. Notify risk management b. Inform the transferring agency of the client’s condition c. Privately interview the client about her condition d. Contact the family regarding the client’s condition 75. Client receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration? a. History of GERD b. Sitting in a high-Fowler’s position during the feeding c. A residual of 65 mL 1 hr. postprandial d. Receiving a high osmolarity formula 76. Adverse effects of sertraline a. Dry cough b. Increased urinary frequency c. Metallic taste in mouth d. Excessive sweating (pharm pg. 53: serotonin syndrome) 77. Teaching for a client undergoing radiation therapy and has stomatitis. Which of the responses by the client indicates an understanding of the teaching? a. “I should limit my intake of dairy products to prevent nausea.” b. “I should use a soft-bristle toothbrush to clean my teeth after meals.” c. “I should moisten my lips with lemon-glycerin swabs.” d. “I should gargle with an alcohol-based mouthwash to kill germs.” 78. Client placed in seclusion and restraints. Which of the following actions should the nurse plan to take? a. Ensure that the prescription for restraints be renewed every 6 hr. b. Have a provider evaluate the client in person within 1 hr. c. Plan to monitor the client every 30 min while restrained d. Complete a written record regarding the seclusion and restraint every 2 hr. 79. Client with acute glomerulonephritis. Which of the following food choices should the nurse recommend? (low in potassium, sodium, and protein) a. Bagel b. Banana c. Eggs d. Smoked salmon 80. Client asks about acupuncture to manage his osteoarthritis pain. The nurse should identify which of the following conditions as a contraindication for receiving this treatment? a. HTN b. Herpes zoster c. Obesity d. Hypothyroidism 81. Reviewing client’s lab results. Which of the following should the nurse review to evaluate the client’s nutritional status? a. Serum albumin b. Serum sodium c. Troponin d. ESR 82. Nurse manger observes two staff nurses reviewing the computer records of a client who is not under their care. Which of the following should the nurse manager take first? a. Request the nurses present an in-service on client confidentiality b. Place documentation of the nurses’ actions in the personnel file c. Instruct the nurses to close the client’s computer record d. Advise the nurses to read the facility’s confidentiality policy 83. Discharge teaching to a client who does not speak the same language as the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take? a. Use gestures to convey meaning b. Speak slowly when talking to the interpreter c. Speak directly to the client d. Pause in the middle of the sentences 84. Teaching the parents of a client with new onset of seizures and is to undergo an EEG. Which of the following instructions should the nurse include in the teaching? a. “Ensure the child’s hair is clean and without conditioner before the procedure.” (medsurg pg. 18: instruct client to wash his hair prior to the procedure and eliminate all oils, gels, and sprays) b. “Keep the child out of the sun for 4 hr. following the procedure.” c. “Make the child NPO before the procedure.” d. “Give the child acetaminophen for pain following the procedure.” 85. Client presented with fine hair, exophthalmos, and reports intolerance to heat. Which of the following endocrine disorders is associated with these findings? a. Hyperthyroidism b. Hyperparathyroidism c. Hypothyroidism d. Hypoparathyroidism 86. Client on bed rest. The nurse should recognize that which of the following findings is a complication of immobility? a. Decreased serum calcium levels b. Increased BP c. Urinary frequency d. Swollen area on calf 87. A nurse is preparing a client to undergo a cardiac catheterization. Which of the following tasks should the nurse perform prior to the procedure? (medsurg pg. 164) a. Administer nitroglycerin 0.4 mg SL 30 min before the procedure b. Draw blood specimens for culture and sensitivity c. Transport the client to radiology for a CT scan d. Obtain CBC with differential 88. A nurse is providing teaching to the parents of a newborn genetic screening. Which of the following statements should the nurse include in the teaching? a. “This test should be performed after your baby is 24 hours old.” b. “A nurse will draw blood from your baby’s inner elbow.” c. “This test will be repeated when your baby is 2 months old.” d. “Your baby will be given 2 ounces of water to drink prior to the test.” 89. New prescription for carbidopa-levodopa. Which of the following instructions should the nurse include? a. “Take with a protein shake.” b. “Report dark-colored urine.” c. “Monitor for hyperglycemia.” d. “Change positions slowly.” (pharm pg. 93: orthostatic hypotension) 90. Identify ECG [IMAGE] of client with potassium toxicity 91. Client in postpartum taking methylergonovine. The nurse should recognize that which of the following is a contraindication for this medication? a. HTN (pharm pg. 253: contraindications/precautions) b. Polyuria c. Confusion d. Chlamydia 92. Parent of an infant who has a cleft lip palate. Which of the following feeding techniques should the nurse include in the teaching? a. Position the nipple at the front of the infant’s mouth b. Burp the infant frequently during feedings (peds pg. 139) c. Use feeding devices without nipples d. Hold the infant in a supine position 93. Client with Alzheimer’s disease. Which of the following should the nurse include in the plan of care? a. Encourage physical activity prior to bedtime b. Replace the carpet with hardwood floors c. Wear clothing with zippers instead of buttons d. Place locks at the top of exterior doors (medsurg pg. 46: installing door locks that cannot be easily opened) 94. A nurse is caring for a newborn whose mother was taking methadone during her pregnancy. Which of the following findings indicates the newborn is experiencing withdrawal? a. Acrocyanosis b. Bulging fontanels c. Bradycardia d. Hypertonicity 95. A newly LPN working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention? a. Using an electronic massaging system to remind clients when to take medications b. Educating clients about contraindications to specific immunizations c. Helping clients understand health screenings covered by their insurance plans d. Providing clients with info about the benefits of exercise 96. Client who has bipolar disorder and is experiencing mania. Which of the following should the nurse include in the plan? a. Encourage the client to take frequent rest periods b. Encourage the client to spend time in the day room c. Place the client in seclusion when he exhibits signs of anxiety (mental pg. 76: seclusion might be the only way to safely decrease stimulation) d. Withdraw the client’s TV privileges if he does not attend group therapy 97. A nurse in the ER is receiving report for four clients. Which should the nurse see first? a. Client who has HTN and reports severe headache (stroke) b. Client who reports left arm pain following a fall c. Client who has heart failure and received diuretic 30 min ago d. Client who reports frequent and painful urination 98. A nurse is visiting a client whose partner states that she is overwhelmed by caring for him. When suggesting respite care, which of the following explanations should the nurse provide? a. “Respite care provides clinicians to work with you in caring for your husband.” b. “Respite care allows for time away from caring for your husband.” c. “Respite care includes volunteers who will perform household tasks.” d. “Respite care offers financial resources to help care for your husband.” 99. Education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching? a. Fibrocystic breast disease b. Fibromyalgia c. Renal calculi d. HTN (pharm pg. 246: use cautiously in clients who have hypertension) 100. Admitting a client who is in labor and at 38 weeks of gestation. The client has a history of herpes simplex virus 2. Which of the following questions is most important for the nurse to ask the client? a. “Are you currently taking acyclovir?” b. “Do you have an active lesion?” c. “When did your labor begin?” d. “How long ago were you first diagnosed?” 101. A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching? a. Leaving a NG tube clamped after administering oral medication b. Administering potassium via IV bolus c. Documenting communication with a provider in the progress notes of client’s medical record d. Placing a yellow bracelet on a client who is at risk for falls 102. Lab results of a client who has osteomyelitis and is receiving tobramycin. Which of the following findings indicate the client is experiencing an adverse effect of the medication? a. Serum creatinine 0.4 mg/dL b. Albumin 3.2 g/dL c. Total bilirubin 0.08 mg/dL d. BUN 30 mg/dL 103. A nurse is teaching a client who is trying to conceive. Which of the following should the nurse instruct the client to increase in her diet to prevent a neural tube defect? a. Zinc b. Calcium c. Folate d. Iron 104. The nurse practices the ethical principles of distributive justice by performing which of the following? a. Ensuring that a client who is homeless receives preventive medical care b. Being honest with the parents of a child about the need to report suspected abuse c. Keeping a promise to visit with a client who is housebound after the delivery of care d. Accepting the decision of an older adult client to live alone in her home 105. Client who is to receive alteplase recombinant for a thrombus in the coronary artery. Which of the following actions should the nurse include in the plan of care? a. Observe for bruising of the skin b. Provide a diet low in protein c. Monitor v/s every hour for the first 4 hr. d. Administer medications intramuscularly 106. Client with dementia. Which of the following actions should the nurse take to reduce the risk for client injury? a. Keep the television on during the night b. Place the bedside table at the foot of the bed c. Raise the side rails up when the client is in bed d. Assist the client to the toilet frequently 107. Assessment of an 8 y/o child. Which of the following findings indicates the need for intervention by the nurse? a. Client eats at least one snack daily b. Client’s weight has increased by 0.9 kg (2 lb.) c. Client’s height has increased by 6.35 cm (2.5 in) d. Client drinks 3 cups of 1% milk per day 108. Client following thyroidectomy. For which of the following complications should the nurse assess the client? a. Muscular depression b. Laryngeal stridor c. Hypokalemia d. Hyperglycemia 109. Teaching to a client who is at 12 weeks gestation. The nurse should tell the client that she will undergo which of the following screening tests at 16 weeks of gestation? a. Maternal serum alpha-fetoprotein b. Chorionic villus sampling c. Cervical cultures for chlamydia d. Nonstress test 110. A certified IV nurse is providing education about PICC to a newly LPN. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (medsurg pg. 166) a. “Position the client’s arm in adduction for PICC placement.” b. “Informed consent is required prior to PICC placement.” c. “Use a vein in the middle of the lower arm to insert a PICC.” d. “Flush a PICC using a 3 mL syringe.” 111. Which of the following clients should the nurse refer for speech therapy? a. Client who has dysphagia following a stroke b. Older adult client who has stage III Alzheimer’s disease c. Client who has sensorineural hearing loss d. Client who is postoperative following a tonsillectomy and adenoidectomy 112. Teaching a client who is 41 weeks of gestation about a nonstress test. Which of the following information should the nurse include in the teaching? a. “You should avoid eating or drinking for 4 hours before the test.” b. “You should massage one of your nipples to stimulate contractions of your uterus.” c. “You will need blood work before and after the test.” d. “You will have a Doppler transducer applied to your abdomen during the test.” 113. Management of an older adult client who has difficulty swallowing and occasional choking during meals. The nurse should initiate a referral to which of the following members of the interprofessional care team? a. Social worker b. Respiratory therapist c. Speech-language pathologist d. Occupational therapist 114. A nurse is developing an in-service about personality disorders. Which of the following should the nurse include when discussing borderline personality disorder? a. “The client might act seductively.” b. “The client is exceptionally clingy to others.” c. “The client exhibits impulsive behavior.” (mental pg. 85: compulsiveness and lack of social restraint) d. “The client is overly concerned about minor details.” 115. Client who has thrombocytopenia following chemotherapy. Which of the following statements indicates an understanding of the teaching? a. “I will floss between my teeth every time I brush.” b. “I will use an enema to manage my constipation.” c. “I will remove my shoes when I’m inside my house.” d. “I will wipe my nose instead of blowing it.” 116. A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first? a. Clarify the source of the referral b. Contact the family by phone c. Schedule a time for the home visit d. Implement the nursing process 117. Discharge teaching to a client following a total gastrectomy. The nurse should instruct the client about which of the following medications? a. Ranitidine b. Vitamin B12 c. Metoclopramide d. Vitamin K 118. A nurse is providing an in-service about client evacuation during a afire. Which of the following clients should the nurse instruct the staff to evacuate first? a. Client who is bedridden and wears a hearing aid b. Client who has a fracture and is in balance suspension traction c. Client who is ambulatory and receiving oxygen d. Client uses a wheelchair and is confused 119. A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching? a. “Have your child drink a small glass of water after swallowing the medication.” b. “Repeat the dose if your child vomits within 1 hour after taking the medication.” c. “You can add the medication to a half-cup of your child’s favorite juice.” d. “Limit your child’s potassium intake while she is taking this medication.” 120. A nurse is providing discharge teaching to a client who has CKD and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching? (medsurg pg. 382: “at least 2 L water daily; control protein; restrict sodium, potassium, phosphorous, and magnesium”) a. Consume foods high in potassium b. Eat 1 g/kg of protein per day c. Drink at least 3 L of fluid daily d. Take magnesium hydroxide for indigestion 121. Client who is 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? a. Epigastric pain b. Vomiting c. HTN d. Contractions (OB pg. 34: advise the client to report to her provider if she experiences fever, chills, leakage of fluid, bleeding from insertion site, decreased fetal movement, vaginal bleeding, or uterine contractions after the procedure) 122. Preoperative assessment for a client allergic to several foods. Which of the following food allergies indicates a risk factor for latex allergy? a. Eggs b. Peanuts c. Shrimp d. Bananas 123. Assessing the fontanels of an 8-month-old infant. Which of the following findings should the nurse recognize as an expected finding? a. Both fontanels show molding b. Both fontanels are the same size c. The posterior fontanel is open (closes at 2-3 months) d. The anterior fontanel is open (closes at 18 months) 124. Parents of an infant who has tracheostomy. Which of the following instructions should the nurse include in the teaching? a. “Apply suction for 30 seconds after advancing the catheter.” b. “Set the suction machine to 60 mm Hg.” c. “Instill 2 mL of saline in the tracheostomy prior to suctioning.” d. “Advance the suction catheter just past the point of resistance.” 125. Client asks info regarding organ donation. Which of the following responses should the nurse make? a. “Your name cannot be removed once you are listed on the organ donor list.” b. “I cannot be a witness for your consent to donate.” c. “You must be at least 21 years of age to become an organ donor.” d. “Your desire to be an organ donor must be documented in writing.” 126. Client following abdominal surgery. Which of the following findings should the nurse report to the provider? a. BP 100/70 mm Hg b. Serous drainage on the abdominal dressing c. Temperature 37.6° C (99.7°F) d. Urinary output 20 mL/hr. 127. A nurse at a community health clinic is planning care for an adolescent who recently learned that she is pregnant and is concerned about her ability to afford and care for her baby. Which of the following actions should the nurse take? a. Assist the adolescent in applying for Medicaid b. Refer the adolescent to a local mental health clinic c. Contact the adolescent’s parent for assistance d. Advise the adolescent to lace the newborn for adoption 128. Client with acute angle-closure glaucoma. Which of the following findings should the nurse expect? (medsurg pg. 66: s/s – elevated IOP; decreased/blurred vision; colored halos; pupils nonreactive to light; severe pain and nausea; photophobia) a. Reddened cornea b. Severe periocular pain c. Gray cast to sclera d. Increased light perception 129. Client who is 11 weeks gestation. Which of the immunizations should the nurse recommend? a. Varicella b. Influenza c. Human papillomavirus d. MMR 130. The nurse should identify that which of the following client findings requires follow up care? a. Client who is taking bumetanide and has a potassium level of 3.6 mEq/L b. Client who is taking warfarin and has an INR of 1.8 c. Client who received Mantoux test 48 hr. and has an induration d. Client who is scheduled for a colonoscopy and is taking sodium phosphate 131. Assessment of client in active labor. Which of the following findings should the nurse report to the provider? a. FHR baseline 170/min b. Contractions lasting 80 seconds c. Temperature 37.4° C (99.3° F) d. Early decelerations in the FHR 132. Client who has DVT of the left lower extremity. Which of the following actions should the nurse take? [View Exhibit] a. Massage the affected extremity every 4 hr. b. Position the client with the affected extremity lower than the heart c. Administer acetaminophen d. Withhold heparin IV infusion 133. A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching? a. “I can visit my nephew who has chickenpox 5 days after the sores have crusted.” b. “I can clean my cat’s litter box during my pregnancy.” c. “I should wash my hands for 10 seconds with hot water after working in the garden.” d. “I should take antibiotics when I have a virus.” 134. Discharge teaching for metoprolol. Which of the following should the nurse instruct the client to monitor and report to the provider? a. Polyuria b. Bradycardia c. Tinnitus d. Hyperglycemia 135. The nurse should recognize that which of the following clients is at greatest risk for developing acute poststreptococcal glomerulonephritis? a. 18 y/o girl who is in the second trimester of pregnancy b. 7 y/o boy who is recovering from impetigo c. 2 month old girl who has pyloric stenosis d. 16 y/o boy who has appendicitis 136. Teaching a client who has migraine headaches how to use biofeedback to reduce the need for pharmacological interventions. Which of the following information should the nurse include in the teaching? a. “Biofeedback stimulates certain pressure points to relax muscles.” b. “Biofeedback uses herbs to reduce inflammation.” c. “Biofeedback requires concentration to control physiological responses.” d. “Biofeedback improves energy flow through soft tissue manipulation to increase circulation.” 137. Client with ALS and has recent weight loss. Which of the following is the priority admission data for the nurse to obtain? a. Changes in appetite b. Swallowing ability c. Prescribed medications d. Daily fluid intake 138. Teaching a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? (OB pg. 60) a. Bleeding gums b. Urinary frequency c. Faintness upon rising d. Swelling of the face 139. Client who has COPD and severe dyspnea. To promote intake, which of the following actions should the nurse include in the plan of care? (medsurg pg. 130) a. Offer the client three large meals each day (increased work of breathing increases caloric demands) b. Limit fluid intake with meals (encourage fluids to promote) c. Administer a bronchodilator after meals d. Ambulate the client before each meal 140. Client experiencing pulmonary embolism. Which of the manifestations should the nurse expect? a. Bradycardia b. Frothy sputum c. HTN d. Dyspnea 141. Client who has permanent drooping on the left side of the face following a CVA. The client refuses to see any family members. Which of the following intervention will best assist the client to adapt to this body image change? a. Establish short-term goals that will enable the client to look in a mirror b. Offer contact information for CVA recovery support groups c. Initiate a family conference to address the issue d. Educate the client about short and long term effects of CVA 142. Caring for a client who has diarrhea and is receiving intermittent enteral feedings. Which of the following actions should the nurse take? a. Discard the open can of formula after 36 hr. b. Administer feedings at a slower rate (medsurg pg. 297: “diarrhea – slow the rate of feeding and notify provider) c. Provide chilled formula d. Flush the tube with 10 mL of water after feedings 143. Providing teaching about exercise to a client who is at 28 weeks of gestation. Which of the following statements by the client indicates an understanding of the teaching? a. “I should drink 16-24 oz. of water after I exercise.” b. “I can continue to do exercises that require the supine position.” c. “I should check my pulse rate once every hour while exercising.” d. “I should increase my exercise level to prepare for labor.” 144. Child who has Lyme disease. Which of the following is an appropriate action for the nurse to take? a. Ensure the state health department has been notified b. Administer antitoxin c. Assess for skin necrosis d. Educate the family to avoid sharing personal belongings 145. Teaching about home safety to an older adult client. Which of the following statements by the client indicates that the teaching has been effective? a. “I have grab bars next to my tub.” b. “I have placed throw rugs in the hallways.” c. “I put on socks when getting out of bed at night.” d. “I have marked the steps with black tape.” 146. The leader of the group uses a laissez-faire leadership style. Which of the following actions should the nurse expect from the leader during the session? a. The leader lectures about medication adverse effects to the group members b. The leader has group members vote on what they would like to learn about during the session c. The leader allows the group to discuss whatever they would like to regarding their medications d. The leader encourages group members to remain silent until questions are called for 147. A nurse is building a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take during the orientation phase of the relationship? a. Establish the responsibilities of the nurse and client b. Determine previous coping skills used by the client c. Facilitate the client’s problem-solving skills d. Assist the client in expressing alternative behaviors 148. A nurse is teaching self-administration of insulin glargine to a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? a. “I will not mix this insulin with other types of insulin.” b. “I will shake the vial to mix the insulin.” c. “I will take this insulin before meals.” d. “I will rotate the injection sites between my arm and my thigh.” 149. Dietary teaching to a client diagnosed with irritable bowel syndrome. Which of the following recommendations should the nurse include? (medsurg pg. 328: “avoid dairy, wheat, corn, fried foods, alcohol, spicy foods, and aspartame”) a. Increase intake of milk products b. Sweeten foods with fructose corn syrup c. Increase intake of foods high in gluten d. Consume food high in bran fiber 150. A nurse is caring for a client in an inpatient facility who tells the nurse that she is leaving because the facility policy prohibits smoking inside. Which of the following actions should the nurse take? a. Place the client in seclusion b. Call the provider for a discharge prescription c. Notify security to monitor the facility’s exits d. Inform the client of the risks involved if she leaves 151. Client having an acute MI. Which of the following findings places the client at risk if he receives alteplase? a. Hip arthroplasty 1 week ago b. Family of malignant HTN c. Acute renal failure 6 months ago d. COPD 152. Assessment for a client who is in the manic phase of bipolar disorder. Which of the following behaviors should the nurse expect? a. Performance of ritualistic behaviors b. Distractibility and poor judgment c. Reports of physical discomfort d. Suspiciousness and distrust 153. Toddler who has retinoblastoma. Which of the following findings should the nurse expect? a. White eye reflex nystagmus b. Hyphema c. Opacity of the lens 154. Child who reports migraine headaches for the past 4 months. Which of the following actions should the nurse take first? a. Refer the family to a chronic pain support group b. Request a change in medication from the provider c. Set up an appointment with the school nurse d. Review the child’s electronic pain diary 155. Client with acute diverticulitis. Which of the following diets should the nurse recommend to the client? a. Lactose-free b. Low-fiber (medsurg pg. 337: “clear liquid diet until manifestations subside; can progress to low-fiber diet as tolerated) c. High residue d. Gluten-free 156. Lab results for a client with heart failure. Serum potassium level of 5.2 mEq/L. Which of the following medications should the nurse withhold? a. Spironolactone b. Metoprolol c. Atorvastatin d. Furosemide 157. Client who is 48 hr. postoperative following a total hip arthroplasty. Which of the following actions should the nurse include in the plan of care? a. Place the client on a full liquid diet b. Administer low-dose heparin c. Maintain the client on bed rest d. Use and incentive spirometer every 3hr 158. A nurse in an acute care facility is caring for a client who is homeless and has a decubitus ulcer. Which of the following actions should the nurse take as a client advocate? a. Gather dressing supplies for the client’s discharge b. Consult with the facility’s quality improvement team c. Contact the facility’s case management department d. Provide client teaching about nutrition 159. A charge nurse observes a coworker who has impaired coordination and is drowsy while performing routine tasks. Which of the following actions should the charge nurse take first? a. Obtain support from another nurse before filing a report b. Document observations about the nurse’s behavior c. Reassign the nurse’s client-care duties to another nurse d. Report the nurse’s behavior to the nurse manager 160. A nurse is caring for a client who has UTI and has been taking cefaclor. Which of the following serum laboratory results indicates the medication is effective? a. Eosinophils 3.9% b. WBC 9,200/mm3 c. Bun 32 mg/dL d. Creatinine 2.3 mg/dL 161. Client who recently attempted suicide states, “I wish I was dead.” Which of the following is an appropriate response by the nurse? a. “Did you take your medications today?” b. “Suicide is not the answer to your problems.” c. “Don’t worry. Everything will be just fine.” d. “You seem like you’re feeling hopeless.” 162. A nurse hears an AP telling the client, “If you don’t eat, I’ll put restraints on your wrists and feed you.” The nurse should intervene and explain to the AP that this statement constitutes which of the following torts? a. Malpractice b. Battery c. Assault d. Negligence 163. ???? 164. DRUG CALC: 100 mL/hr. 165. ???? 166. Toddler who has cystic fibrosis. Which of the following instructions should the nurse include? a. “Perform chest percussion and postural drainage at least twice daily.” b. “Administer pancreatic enzymes on an empty stomach.” c. “Restrict intake of foods that contain gluten.” d. “Use a nebulizer to administer a bronchodilator following airway clearance therapy.” 167. Which of the following actions should the nurse take to verify NG tube placement prior to each feeding? a. Palpate the abdomen for tube placement b. Test the pH of gastric contents c. Test the bilirubin level of gastric contents d. Auscultate air insertion into the tube 168. Infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding? a. Weak femoral pulses (peds pg. 112) b. Upper extremity hypotension c. Increased ICP d. Frequent nosebleeds 169. Client with schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine a. Heart rate 58/min b. Fasting blood glucose 100 mg/dL c. Hgb 14 g/dL d. WBC count 2,900/mm3 (pharm pg. 72: agranulocytosis) 170. Which of the following statements by the newly licensed nurse indicates an understanding of advance directives? a. “I’ll encourage clients to follow their provider’s wishes for end of life care.” b. “I have to document whether or not a client has prepared his advance directives.” c. “I have to witness a client’s signature on his advance directives.” d. “I’ll refer clients who do not have advance directives for legal assistance.” 171. Client who has depressive disorder and a new prescription for phenelzine. Which of the following foods should the nurse instruct the client avoid? a. Smoked salmon b. Cottage cheese c. Spinach d. Grapefruit 172. Client diagnosed of acute MI and is being treated with a thrombolytic, aspirin, and IV heparin. Which of the following findings should indicate the nurse that the client is experiencing a satisfactory response to these interventions? a. Q wave is noted on the cardiac monitor tracing b. S3 heart sounds are present c. The client’s aPTT is two times the control d. The client’s stool is guaiac positive 173. A nurse is assessing the PICC of a client who is receiving an infusion. The nurse notices redness and warmth to touch around the insertion site. The nurse should document the finding as which of the following complications? a. Circulatory overload b. Extravasation c. Phlebitis d. Infiltration 174. Which of the following solutions should the nurse use to perform hand hygiene? a. Isopropyl alcohol b. Providone-iodine c. Bleach d. Chlorhexidine 175. Methods to promote nighttime sleep. Which of the following instructions should the nurse include? a. Perform exercises prior to bedtime b. Take a 1 hr. nap during the day c. Eat a light snack before bedtime d. Stay in bed at least 1 hr. if unable to fall asleep 176. Which of the following actions by the LPN indicates the need for intervention by the charge nurse? a. Inserts an NG tube for a client using clean technique b. Stabilizes a client’s indwelling urinary catheter with the nondominant prior to inflation of the balloon c. Uses an IV infusion pump to administer TPN nutrition to a client d. Crushes an SL tablet to administer into a client’s feeding tube 177. A 3-day old newborn that has a congenital heart defect. Which of the following interventions should the nurse include to decrease cardiac demands for the newborn? a. Feed the infant when she is awake and crying b. Maintain the infant’s temperature at 37° C (98.6° F) c. Encourage the infant’s parents to limit visitation and physical touch d. Keep the infant’s bed in a flat position 178. ???? 179. A nurse is teaching a parent about absence seizures. Which of the following information should the nurse include? a. “The child usually has an aura prior to onset.” b. “This type of seizure can be mistaken for daydreaming.” c. “This type of seizure has a gradual onset.” d. “This type of seizure lasts 30-60 seconds.” 180. A nurse on a medical-surgical unit is delegating tasks to an AP. Which of the following client care tasks is within the scope of practice for the AP? a. Explaining the steps for a 24-hr urine collection b. Assisting with low-carbohydrate diet selections c. Interpreting blood glucose values d. Performing postmortem care