ATI PN COMPREHENSIVE 2017
PROCTORED
•A nurse is caring for a client who has a recent diagnosis of a terminal
illness. The nurse should identify which of the following as an
indication of hopelessness?
o The client
...
ATI PN COMPREHENSIVE 2017
PROCTORED
•A nurse is caring for a client who has a recent diagnosis of a terminal
illness. The nurse should identify which of the following as an
indication of hopelessness?
o The client wants to talk about the diagnosis with nursing staff
o The client has a decreased energy level
o The client makes funeral arrangements
o The client requests a second opinion
•A nurse is preparing to collect data on a preschooler. Which of the
followingbehaviorsbythechildindicatesthatheisreadytocooperate?
(Select all that apply)
o Allows the nurse to touch him on the arm
o Plays with toys in
the examining
room
o c. Answers questions asked
by the nurse
o d. Makes eye contact with the
nurse
•Sits on his parent’s lap when the nurse enters the room
•A nurse on a mental health unit is planning care for a group of
clients.Whichofthefollowingclientsshouldthenursesee
first?
o A client who has bipolar disorder and is displaying flights of ideas
o A client who has ADHD and has an inability to concentrate
o A client who has schizophrenia and is having commandhallucinations
o A client who has depressive disorder and is withdrawn
•A nurse is caring for a client who recently gave birth to her first child. The
newborn is crying and the client states, “ I can’t seem to do anything right.
What should I do?” Which of the following responses should the nurse
make?
o “I’ll take him back to the nursery, so you can get some rest.”
o “Babiesneed to cry soon after they are born to develop their lungs.”
o “Let me show you how to swaddle and cuddle him, then you try.”
o “If I turn him on his side, maybe he’ll go back to sleep.”
•Anurseisusingaglucometer tomeasureaclient’scapillarybloodglucose
level, Which of the following actions should the nurse take?
o Test the first drop of blood that forms after the puncture
o Wear sterile gloves
o Keep the finger in a dependent position
o Select the central tip of the finger
•A nurse is reviewing the home medications of a client who recently had
transientischemicattacksandistobegintakingclopidogrel.The nurse
should instruct the client that which of the following over-the-counter
medications interacts adversely withclopidogrel?
o Docusate sodium
o Ranitidine
o Vitamin D3
o Naproxen
•Anurseiscollectingdatafromaclientwhohasalonglegcastthatwas
applied 2 days ago. The client’s foot is pale with a weak pedal pulse, and the
clientreportsfoot numbness. Whichofthefollowingactionsshouldthe
nurse plan to take first?
o Administer opioid pain medication
o Apply an ice pack to the affected extremity
o Check for pain with passive movement of the affected extremity
o Elevate the affected extremity with several pillows
•A nurse in a provider’s office is reinforcing teaching about cigarette smoking
with a client. Which of the following adverse effects should the nurse
include in the teaching?
o Decreased hemoglobin
o Somnolence
o Bradycardia
o Decreased blood pressure
•Anurseiscontributing tothedevelopment ofanin-serviceprogramfor
mentalhealthnursingstaff. Thenurseshould includethat thest
•aff can medicate a client against his will, without a court hearing,in which
of the following situations?
o A client who has a serious mental illness
o A client who is having difficulty making decisions about his treatment
o A client for whom the benefits of the medication outweigh the risks
o A client who is attempting to hurt himself or others
•A nurse is reinforcing teaching with a client who has a new prescription for
digoxin. Which of the following instructions should the nurse include in
the teaching?
o “Monitor for muscle weakness while taking the medication.”
o “Rotate injection sites when administering the medication.”
o “Withholdthemedicationifyourpulserateisabove100beats
per minute.”
o “Increase your intake of dietary fiber to increase absorption.”
•A charge nurseis discussing confidentiality requirements with a newly licensed
nurse when sharing a client’smedical information. Which of the following
individuals should the charge nurse identify as appropriate with whom to
share client information?
o A nurse from another unit after a client commits suicide
o A social worker who is assigned to an involuntary committedschool-age
client
o A client’s partner after the client reports intimate partner abuse
o A client’s employer who is concerned about safety due to substance
use
•Anurseisreviewinglaboratoryvaluesforaclientwhoisat34weeksof
gestation.Whichofthefollowingfindingsshouldthenursereporttothe
provider?
o Hgb 13.2 g/dL
o Urine protein 3 plus
o Fasting blood glucose 72 mg/dL
o BUN 15 mg/dL
•A nurse is collecting data from a client who is 4 hr postoperative
following a hemicolectomy. Which of the following findings is the nurse’s
priority, requiring immediateintervention?
o Pain rating of 9 on a scale from 0 to 10
o Blood pressure 160/90 mm Hg
o Oxygen saturation 89%
o Abdominal dressing with a moderate amount of bright red drainage
•A nurse in a provider’s office is collecting data from a client who has a
historyofhypertensionduringhisannualphysicalexamination.Whichof
the following findings should the nurse report to the provider
immediately?
o A 2 kg (4.4 lb) weight gain
o Blurred vision
o Potassium 3.6 mEq/L
o Resumption of cigarette smoking
•A nurse is caring for aclient who suddenly develops chest pain and dyspnea.
Which of the following actions should the nurse take first?
o Place the client on bed rest
o Obtain the clients ABG levels
o Prepare the client for a ventilation-perfusion scan
o Elevate the head of the client’s bed
•Anurseisreinforcingteachingonaclient whohasdiabetesmellitus.
Which of the following laboratory tests is the most accurate of blood
glucose effective management?
o Urine ketones
o Glucose tolerance test
o Glycosylated hemoglobin
o Fasting blood glucose
•A charge nurse ona mental health unit issupervising a newly licensed nurse.
For which of the following actions by the newly licensed nurse should the
supervising nurse intervene?
o Requests a client to assist with distributing lunch trays
o Tells a client he will lose his phone privileges if he does not take his
medication
o Encourages a client to participate in a recreational therapy group
o Placesmechanicalrestraintsonaclientwhoishittinganother
staff member
•A nurse is supervising an assistive personnel (AP) obtain supplies for a client
whoisonseizureprecautions.WhichofthefollowingmaterialsshouldtheAP
place in the client’s room?
o Oral suction equipment
o Wrist restraints
o Tongue depressor
o Tracheostomy tray
•Anurse isreinforcing dischargeteaching with thefaculty of aclient who
has dependent personality disorder. Which of thefollowing instructions
should the nurse indicate in the teaching?
o Maintain a verbal no-harm contract with the client
o Assume responsibility for making the client’s decisions
o Encourage the client to be assertive
o Limit the client’s social interactions
•A nurse is reinforcing discharge teaching with a client who had a right total
hip arthroplasty. Which of the following instructions should the nurse
indicate?
o “You should avoid crossing your legs for 3 months.”
o “You should avoid putting a pillow between your legs when in bed.”
o “You should avoid exercising for the next 6 weeks.”
o “You should avoid lying on your right side.”
•
•A nurse is reinforcing dietary teaching with a client who has
hyperemesisgravidarum.Whichofthefollowinginstructionsshouldthe
nurse include in theteaching?
o Drink 240 mL ( 8 oz) of water with each meal
o Eat a small meal every 2 to 3 hr
o Avoid eating dairy products
o Choose foods that are high in fat
•A nurse is reinforcing teaching with a client who has GERD and a
prescription for ranitidine. Which of the following statements by the
client indicates an understanding of the teaching?
o “I have to remain upright for 1 hour after taking the medication.”
o “I should take this medication in the morning and at night.”
o “I should expect my tongue to turn black after I take this medication.”
o “I have to take this medication on an empty stomach.”
•A nurse is assisting with the admission of a client who has pulmonary
tuberculosis. Which of the following types of isolation precautions should
the nurse include?
o Airborne
o Droplet
o Protective
o Contact
•A nurse is reinforcing discharge teaching with a client who has COPD and
reports problems with maintaining adequate nutrition. Which of the following
instructions should the nurseinclude?
o “Selfadministeroxygenthroughyournasalcannulaat6
milliliters per minute duringmeals.”
o “Perform pulmonary hygiene 1 hour before meals.”
o “Drink at least 240 milliliters of water during each meal.”
o “Lie down for 30 minutes after eating.”
•A nurse is administering pancreatic enzymes to a client who has cystic
fibrosis.Whichofthefollowingoutcomesshouldthenurseexpectasa
therapeutic effect of thetreatment?
o Decreased sodium excretion
o Improved absorption of vitamins B and C
o Improved respiratory function
o Reduced fat in the stools
•A nurse is caring for a client who has paranoid schizophrenia and believes that
she is being followed by FBI agents who are pretending to be psychiatric
staff. Which of the following responses should the nursemake?
o “Why do you feel the staff is the FBI?”
o “What makes you think the staff is following you?”
o “The psychiatric staff is not FBI. They are here to help you.”
o “This must be very frightening for you. Let’s talk more about it.”
•A nurse is assisting in the care of a client who has a fractured femur and
is in Buck’s traction, which of the following actions should the
nurse take?
o Clean the pin insertion sites on a daily basis
o Ensure that the weights are hanging freely
o Apply a 9 kg (20 lb) weight to the traction
o Remove the weights while the client is eating
•A nurseisreviewingthemedicationrecordofaclientwhorequires
continuousoxygensaturationmonitoring.Whichofthefollowingshouldthe
nurseidentifyasafactorthatcanaffectthevalidityofthereadings?
o Calcium level 8.0 mg/dL
o Peripheral vascular disease
o Taking anticoagulant medication
o IV access on the same extremity
•Anurseiscollectingdatafromagroupofclients.Whichofthefollowing
clientsshouldthenurseidentifyashavingxanthelasma?Ladywitheyes
closed with nodule on eyelid
•A nurse is assisting with the admission of a client who has
Vancomycin-resistant enterococcus ofthe urine. Which ofthe
following types of precautions should the nurse implement for
this client?
o Contact precautions
o Droplet precautions
o Airborne precautions
o Protective precautions
•A community health nurse is assisting in the development of a
brochure about hypertension. Which of the following actions should
the nurse take?
o Use a 12 point font size
o Present information from complex to simple
o Explain medical terminology using basic, one-syllable words
o Write the information at an 8th-grade reading level
•A nurse is collecting data from an adolescent during an annual
physical examination. Which of the following statements by the
client is the nurse’spriority?
o “I’m angry with my girlfriend about an argument we had last night.”
o “I have anxiety when I’m in a large group.”
o “I’m not sleeping much because of all the homework I have.”
o “I would rather be alone than with my friends.”
•A nurse is placing a dressing over a stage 1 pressure ulcer on a client’s heel,
which of the following types of wound dressing should the nurse use?
o Gauze packing
o Calcium alginate
o Transparent film
o Adhesive strips
•A nurse is caring for an older adult client who reports pain and has a
prescription for ketorolac 15 mg IM every 5 hr PRN. The client’s current
bloodpressureis114/55mmHg.Whichofthefollowingactionsshould
the nurse take?
o Request a prescription for a different pain medication for the client
o Administer the medication to the client
o Place the client on strict bedrest
o Repeat the client's blood pressure measurement
•A charge nurse in a long-term care facility is developing a performance
improvement plan for an assistive personnel (AP). Which of the following
actions should the nurse take when developing the plans? (Select all that
apply)
o Set a specific time frame for meeting
performance goals b. Ask the nurse supervisor
to review the plan
•Base performance goals on peer comments
•Request clients complete an evaluation about the AP’s quality of care
•Include the performance standard that the AP should meet
o nurse is reinforcing teaching with a client who is undergoing
radiation therapytotheneck.Whichofthefollowinginstructions
should the nurse include in the teaching?
Cleanse the neck by rubbing with a washcloth
Limit fluid intake to 750 mL per day
Eat three large meals each day
Avoid exposing the neck to the cold
•A nurse is assisting with the admission of an older adult client who has
impairedmobility and isatriskforfalls. Which ofthefollowingfall
precautions should the nurse plan to implement?
o Createaschedulewithanassistivepersonnel todohourly
rounding for the client
o Apply rubber-soled slippers before ambulation
o Move the bedside table with the client’s personal items close to the
bed
o Determine the client's ability to use the call light
•A nurse is reinforcing teaching with a client about intermittent catheterization to
measure residual urine. Which of the following information should the nurse
include in the teaching?
o “You cannot drink fluids for 4 hours after the procedure.”
o “You will need to urinate before the procedure.”
o “You will have a leg bag to collect the urine.”
o “You will feel pressure when I inflate the catheter balloon.”
•A nurse is caring for a client who has terminal cancer and has
declined treatment. The nurse attempts to convince the client to reconsider
hisdecisionanddiscussesthisattemptwiththechargenurse.Whichofthe
following actions should the charge nursetake?
o Meet with the client’s family to discuss treatment options
o Performamentalstatusexaminationtoestablishtheclient’scompetency
o Ask the client if he has any financial concerns
o Talk with the nurse about the need to support the client’s decision
•Anurseisreinforcingteachingaboutbreastfeeding withaclient who gavebirth 2
days ago. Which of the following information should the nurse include?
o Allow the newborn to nurse for no more than 10 min on each breast
o Store expressed breast milk in the refrigerator for up to 72 hr
o Feed the newborn 8 to 12 times every 24 hr
o Supplement feedings with 30 mL (1 oz) of water four times per day
•Anurseisassisting withtheadmissionofaschool-agedchild.Which
ofthefollowingactionsshouldthenurseplantotake?(Exhibit)
o Initiate contact precautions for the child
o Place the child on bed rest for 24 to 48 hr
o Restrict the child's intake of foods containing vitamin k
o Keep the child on NPO status for 8 hr
•A nurse is contributing to the plan of care for a client who has ascites
duetocirrhosis.Whichofthefollowinginterventionsshouldthenurse
recommend to include in the plan?
o Keep the client’s daily protein intake below 0.8 g/kg
o Position the client supine with his legs elevated
o Measure the client’s abdominal girth daily
o Restrict the clients sodium intake to 3 g per day
•Anurseisreinforcingteachingwithaclientwhohasaprescriptionforantibiotic
therapy. The clienttells the nurse that healways experiences diarrhea when
he takes antibiotics. Which of the following food choices should the nurse
recommend to lessen the occurence of diarrhea?
o Apple juice
o Ice cream
o Coffee
o Yogurt
•
•Anurseisassistingwiththecareofaclientwhohasincreased
intracranialpressurefollowingaclosedheadinjury.Whichofthe
following actions should the nurse take?
o Monitor the client’s temperature every 4 hr
o Wake the client every 6 to 8 hr
o Elevate the head of the bed to 30 degrees
o Place the client in lateral sim’sposition
•A nurse is assisting with the plan of care for a client who is in the third
trimester of pregnancy and has ankle edema. Which of the following
interventions should the nurse include in the client’s plan of care?
o Administer diuretics
o Limit fluid intake
o Apply support stockings
o Place on bedrest
•A nurse is contributing to the plan of care for a client who is experiencing
delirium. Which of the following interventions should the nurse
recommend?
o Remind the client of the day and time often
o Alternate daily caregivers
o Avoid discussing the client’s fears
o Offer the client several choices at mealtimes
•Acommunityhealthnurseisassistingwiththedevelopmentofa
pamphletregardingchokinghazardsfortoddlers.Whichofthefollowing
foods should the nurseinclude?
o Potatoes
o Oranges
o Grapes
o Corn
•Anurseisreinforcingdischargeteachingwithaclientwhohasanew
diagnosis of tuberculosis. Which of the following instructions should the
nurse include in theteaching?
o “You should have a sputum examination every 4 weeks.”
o “You should obtain a chest x-ray every 3 months.”
o “You should schedule a tuberculin skin test every 6 months.”
o “You should stop taking your antituberculin medication after 2
weeks.”
•A nurseisassistingwiththecareofaclient whoisat37weeksof
gestationandisundergoinganonstresstest.Whichofthefollowing
actions should the nursetake?
o Explain that nonreactivity might require immediate medication
administration
o Tell the client the test should take about 10 min
o Remind the client to press the button when she feels fetal movement
o Assist the client into a supine position
•A nurse is contributing to the plan of care for a client who has dysphagia.
Which of the following interventions should the nurse include?
o Encourage socialization during meal times
o Elevate the head of the clients bed to 30 degrees
o Tilt the client’s head forward during meals
o Provide three large meals per day
•A nurse is reinforcing teaching with a client who is at 18 weeks of
gestation and has a medical history of mild hypertension. For which of
the following findings should the nurse instruct the client to monitor
and report to the provider?
o Leukorrhea
o Epistaxis
o Fatigue
o Persistent headache
•A nurse is talking with the partner of a client who recently died, which
of the following statements should the nurse make?
o “I will call the chaplain to speak to you.”
o “It seems bad right now, but things will get better over time.”
o “Tell me what I can do for you at this time.”
o “I think you should attend a grief support group.”
•A nurse is assisting with the admission of a client who states, “The last time I
was in the hospital, the nurses took forever to answer my call light.”
Which of the following is an appropriate response by the nurse?
o “That must have been a difficult experience for you.”
o “It will not happen this time because we have more staff.”
o “I am sure no one meant to ignore you.”
o “Let’s discuss what brought you to the hospital this time.”
•A nurse in a provider’s office is caring for a group of clients who have
communicable diseases. Which of the following infections should the nurse
report to the state health department?
o Neisseria gonorrhoeae
o Sarcoptes scabiei
o Human papillomavirus
o Impetigo contagiosa
•Anurseisassistingwiththeadmissionofanadolescentclient whois
suspected to have bacterial meningitis. Which of the following findings
should the nurse expect?
o Hematuria
o Nuchal rigidity
o Jaundice
o 2 plus pedal edema
•A nurse is reviewing laboratory findings for four clients. Which of the
followinglaboratoryvaluesisanexpectedfindingforaclientwhohas
end stage kidney disease?
o Creatinine 15 mg/dL
o Potassium 4.0 mEq/L
o BUN 15 mg/dL
o Phosphorus 4.0 mg/dL
•A nurse is caring for a client who is taking warfarin and has an INR of 5.5. The
nurse should expect which of the following instructions from the
provider?
o Obtain an aPTT level
o Change the medication to heparin IV
o Administer protamine sulfate
o Reduce the dosage of the medication
•Anurseisassistingwiththecareofaclientwhoisreceivinga
continuous IV infusion. Which of the following indicates fluid
volume excess?
o Urine output of 360 mL/12 hr
o Blood pressure of 100/74 mm Hg
o Distended neck veins
o Decreased bowel sounds
•A nurse is reinforcing teaching with the parents of an infant who has a
Pavlikharness. Whichofthefollowingstatementsshouldthenurse
include in the teaching?
o “You should place the diaper over the strap of the harness.”
o “Youcanapplylotionunderthestrapsoftheharness.”
o “Theharnesscanberemovedforsleepingeachnight.”
o “The harness can promote hip joint development.”
•A nurse is caring for a client who is 2 days postoperative. The client has a
prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet
every 3 to 4 hr PRN for pain. The nurse inadvertently administers 2 tablets to
theclient.Inwhichofthefollowinglocationsshouldthenursedocument
this error?
o Provider’s progress notes
o Nursing care plan
o Incident report
o Controlled substance inventory record
•Anurseispreparingasterilefieldtoperformadressingchangefora
client’slegwound,whichofthefollowingactionsshouldthenurse
take?
o Place sterile objects at least 2.5 cm (1 in) from the edge of the sterile field
o Hold the irrigation solution bottle 5 cm (2 in) above the sterile
container
o Place the irrigation solution bottle cap on the sterile field
o Open the outer wrapper of the sterile package toward her body
•A nurse begins to bath a newly admitted client who reports that she has not
hadanythingtoeatthatday.Thenurseinterruptsthebathandobtainsa
healthy meal for the client. This action by the nurse is an example of
which of the following?
o Boundary crossing
o Countertransference
o Veracity
o Promoting trust
•A nurseis contributing to the plan of carefor a client who hasherpes
simplex.Thenurseshouldplantoinitiatewhichofthefollowingisolation
precautions when caring for thisclient?
o Contact precautions
o Airborne precautions
o Droplet precautions
o Protective environment
•A nurse is documenting client care in the nurses notes and notices that a
spacewasleftblank.Whichofthefollowingactionsshouldthenurse
take?
o Draw a horizontal line through the space and sign at the end of the line
o Leave the space as it is within the entry
o Place the date at the beginning of the space, followed by double lines
o Black out the line with a felt-tip pen
•A nurse is caring for a client who has AIDS. Which of the following solutions
shouldthenursedisinfecttheclient’soverheadtablefollowingablood
spill?
o Chlorhexidine
o Bleach
o Hydrogen peroxide
o Isopropyl alcohol
•A home health nurse is caring for an older adult client who has rheumatoid
arthritis.Whichofthefollowingfindingsshouldthenurseidentifyasa
safety risk?
o The client's daughter fills the medication organizer once weekly
o The client’s electrical wires are run under carpeting
o The client has a smoke detector in his bedroom
o The client has a raised toilet seat in his bathroom
•Anurseisreinforcingteachingwithaclientwhoisabouttoundergosurgery.
Which of the following statements about informed consent should the nurse
include in the teaching?
o “Afamilymembermustwitnessyoursignatureontheinformed
consent form.”
o “We require informed consent for all routine treatments.”
o “You can sign the informed consent form after the provider explains the
pros and cons of the procedure.”
o “Wecanacceptverbalconsentunlessthesurgicalprocedure
is an emergency.”
•A nurse is reinforcing teaching with a client who has a trichomoniasis
vaginalisinfectionandanewprescriptionformetronidazole.Whichof
the following instructions should the nurse include in the teaching?
o “You should expect your urine to turn brown.”
o “You might develop constipation.”
o “You will need to take the medication for 3 weeks.”
o “Youmighthaveincreasedsalivaproductionwhiletaking
this medication.”
•A nurse is obtaining informed consent from a client who is scheduled for
aninvasiveprocedure.Theclientstates,“Idon'tunderstandwhythis
procedure is necessary.” Which of the following actions should the
nurse take?
o Remind the client about the specifics of the procedure
o Explain to the client that the procedure will help treat his diagnosis
o Ask the client to sign the consent form anyway
o Notify the charge nurse about the situation
•A nurse is reviewing information about advance directives with a newly
admittedclient.Whichofthefollowingstatementsbytheclientindicatesan
understanding of the information?
o “Advance directives include a living will”
o “Federallegislationdictatesthelegal guidelinesforadvancedirectives.”
o “My medical record should not include my advance directives.”
o “Advance directives include instructions for resolving financial matters after
my death.”
•A nurse is collecting data from the caregiver of a client who has Alzheimer’s
disease.Thecaregiverreportstheclienthasdifficultysleepingatnight
andwandersthroughoutthehouse.Whichofthefollowinginterventions
should the nurse recommend?
o Encourage the client to take frequent walks during the day
o Give the client a barbiturate medication at bedtime
o Allow the client to nap for at least 1 hr during the day
o Put a simple lock on the clients bedroom door
•A nurse is assisting in the care of a client who is 8hr postpartum and has uterine
atonywithincreasedbleeding.Whichofthefollowingactionsshouldthenurse
take? (Select all that apply)
o Check the clients capillary refill
o Administer terbutaline 0.25 mg subcutaneous
o Give the client 800 mg of ibuprofen
o Massage the client's fundus
o Assist the client to empty her bladder
•A nurse is reinforcing teaching with the support person of a client who is in
thefirststageoflabor.Whichofthefollowinginstructionsshouldthe
nurse include regarding effleurage?
o “Apply steady pressure with this tennis ball to her sacral area.”
o “Assist her to breathe in deeply at the beginning of each contraction.”
o “Gently stroke her abdomen during contractions.”
o “Help her to focus on an object in the room.”
•A nurse is caring for an older adult client who is postoperative following a
total hip arthroplasty. The client is incontinent of stool and urine. Which of
the following actions should the nurse take to prevent skin breakdown?
o Massage the area around the clients coccyx
o Limit the client’s fluid intake
o Use a moisture barrier on the client’s skin
o Clean the client’s skin with soap and hot water
•A nurse is caring for a client who has terminal cancer. Which of the
followingactionsshouldthenursetaketopromotetheclient’s
autonomy?
o Be honest with the client about the prognosis
o Allow the client to choose treatment times
o Provide privacy during client care procedures
o Administer pain medication on a routine schedule
•A nurse in a clinic is caring for a client who is at 40 weeks of gestation
and experiences a sudden gush of vaginal fluids. Which of the following
findings is evidence of an obstetric complication?
o Turns a nitrazine strip blue
o Appears greenish-brown in color
o Preceded by bloody mucus
o Has a pH of 7
•Anurseisassistingwiththecareofanadolescentclientimmediately
followingalumbarpuncture.Whichofthefollowingactionsshouldthe
nurse take?
o Administer opioids to the adolescent on a schedule
o Position the adolescent with his neck hyperextended
o Keep the adolescent NPO
o Inform the adolescent that he might experience a headache
•Anurseisreinforcingteachingaboutadvancedirectiveswithaclientwhohas
end-stageheartfailure.Whichofthefollowingstatementsbytheclient
indicates an understanding ofthe teaching?
o “I am not allowed to change my mind once I sign this document.”
o “Mypartner needstobe presentwhenIsign thisdocument.”
o “I should discuss this document with my family after I sign it.”
o “An attorney will need to notarize this document for it to be valid.”
•A nurse is caring for a client who has continuous bladder irrigation
following atransurethral resectionoftheprostate.Thenursenoticesclots
anddarkredbloodinthecathetercollectionbag.Whichofthefollowing
actions should the nurse take?
o Clamp the urinary catheter tubing
o Irrigate the bladder with 20 to 30 mL of 0.9% sodium chloride irrigation
o Replacethe indwelling urinary catheterwitha smaller diameter catheter
o Allow the tubing to hang below the drainage bag
•A nurse is planning to obtain a 12-lead ECG for a client who has a
historyofcardiacdysrhythmias.Whichofthefollowingactions
should the nurse plan totake?
o Instruct the client to remain as still as possible during the recording
o Assist the client to the orthopneic position
o Tell the client to expect a mild stinging sensation
o Attach a blood pressure cuff to the clients upper arm
•A nurse is reinforcingteachingwith a client who has genital herpes. Which
ofthefollowinginformationshouldthenurseincludeintheteaching?
o “You should increase fluid intake to relieve dysuria.”
o “Youwill no longerbe infectiousonceyou have completeda
course of antibiotics.”
o “You should wear nylon underwear until the lesions have healed.”
o “You should have the lesions drained as they appear.”
•A nurse is preparing to empty a postoperative client’s closed-wounddrainage
system. Which of the following actions should the nurse plan to
take?
o Apply sterile gloves prior to handling the drainage system
o Attach the drainage tube to low-intermittent suction
o Cleanse the drainage port with soap and warm water
o Compress the container before replacing the drainage plug
•A nurse is reinforcing teaching with the parents of a toddler who has a
newdiagnosisofasthmaandaprescriptionformontelukast.Whichofthe
following instructions should the nurse include in the teaching?
o Administer the medication when the toddler has an acute asthma
attack
o Mix the medication in juice prior to administration
o Provide an additional dose of the medication prior to physical activity
o Administer the medication to the toddler each evening
•A nurse in an acute mental health facility is caring for a newly admitted client.
Whichofthe following should occur during the orientation phase of the
nurse-client relationship?
o Overcoming resistance
o Promoting insight
o Defining responsibilities
o Examining one’s feelings
•A nurse is caring for a client who reports having a decrease in fetal
movement following an external cephalic version 6 hr ago. The nurse
identifies the fetus is in the right occiput anterior position. The nurse should
place the fetal heart monitor on which of the following sites to auscultate
the fetal heart rate? Lower left
•Achargenurseisobserving anewlylicensed nurseperformsuctioning fora
client who has a tracheostomy. For which of the following actions by the
newly licensed nurse should the charge nurse intervene?
o Preoxygenates with 100% oxygen
o Suctions for 30 seconds
o Auscultates breath sounds
o Applies suction during catheter removal
•A nurse is reviewing the medication administration record of a client who
takes atenolol PO and supplies a nitroglycerin transdermal patch daily.
Whichofthefollowinginteractionsshouldthenursemonitorwiththis
client?
o Thrombocytopenia
o Dry cough
o Hypotension
o Hyperglycemia
•A nurse in an acute care setting is preparing to administer medications to a
client. Which of the following actions should the nurse verify the
client's identity?
o Verify the client’s identity with a family member
o Ask the client the name of the facility
o Ask the client to state her first name
o Verify the client’s identity using a photograph
•A nurse in a provider’s office is collecting data from a client who has
psoriasis.Whichofthefollowingstatementsmadebytheclient
should she report to the provider?
o “I do not use fabric softener when I wash my clothing.”
o “I limit my time spent out in the sunlight.”
o “I remove old medication on my skin before applying a new dose.”
o “I try not to look at the scales on my body.”
•A nurseis completing chart reviews inalong-term carefacility in response
to an increase in falls. Which of the following responses in the chart
should the nurse use to determine the potential causes of falls?
o Medication record
o Admission face sheet
o Pastoral care notes
o Social activities report
•Anurseismakingclientcareassignmentsforanassistivepersonnel(AP).
Which of the following tasks should the nurse assign to the AP?
o Evaluate the need to suction the airway of a client who has a
new tracheostomy
o Inspecttheincisionofaclientwhoispostoperativefollowinga
leg amputation
o Feed a client who has difficulty swallowing liquids following a stroke
o Complete post mortem care for a client who has died
•Anurse isreinforcing teachingwith aclient who istaking allopurinol aboutthe
risk for developing Stevens-Johnsons syndrome. For which of the following
manifestations should the nurse instruct the client to monitor and report?
o Hyperreflexia
o Skin rash with fever
o Tinnitus with ear pain
o Diplopia
•Achargenurseinalong-termcarefacilityisreinforcingteachingwitha
groupofnursesaboutfallprecautions.Whichofthefollowingstatements
made by the nurse indicates an understanding of the teaching?
o “I will instruct the client to sit when putting on a pair of pants.”
o “I will instruct the client to sit in a low-rise chair.”
o “I will instruct the client to wear socks when ambulating to the
bathroom at night.”
o “I will instruct the client to bend at the waist when picking up an
object.”
•A nurse is recommending clients for discharge to allow for admission of
clients following a tornado disaster. Which of the following clients
should the nurse recommend for discharge?
o A client who reports chest pain after ambulating
o A client who has atrial fibrillation and an INR of 4
o A client who has a sodium level of 140 mEq/L after one episode of diarrhea
o Aclientwhois3dayspostoperative followingahiparthroplastyand
has a warm, red area on his left calf
•A nurse is assisting with the plan of care for a newly admitted client who
has anorexia nervosa. Which of the following interventions should the
nurse include in the plan?
o Obtain vital signs once per day
o Administer liquid supplements
o Weigh the client weekly
o Discuss food topics during mealtime
•Achargenurseisreinforcingteachingwithanewlylicensednurseabout
floatingtoadifferentunit.Whichofthefollowingstatementsbythe
newlylicensed nurse indicates an understanding of the teaching?
o “I will delegate any tasks I do not have the skill to perform to
assistive personnel.”
o “Iwill be protected from liability if Iamappointed with aresource nurse
when I float.”
o “I will document in the medical record the support nurse who assists with
planning care for my clients.”
o “IamnotliableifIperformdelegatedfunctions whensupervision is
not provided.”
•A nurse is caring for a client who has dehydration due to diarrhea. Which
of the following findings should the nurse report to the provider?
o Serum creatinine 1.0 mg/dL
o Urine specific gravity 1.020
o Urine output 12 mL/hr
o BUN 18 mg/dL
•Anurseisparticipatinginaperformanceimprovementprogram.Whichof
the following actions should the nurse take to evaluate the
effectiveness of the program?
o Define the problem
o Identify data collection methods
o Perform chart audits
o Review the facility’s policy and procedure manual
•Anurseinanassisted-livingfacilityisreinforcingteachingwithstaff
membersaboutpreparingforanexternalchemicaldisaster.Whichofthe
following instructions should the nurse include?
o “Cover the electrical outlets with wet towels.”
o “Turn on fans in the facility to circulate air.”
o “Open the fireplace dampers in the day room.”
o “Move clients to a room above ground with few windows.”
•A nurse is assisting in the care of a client who has an arteriovenous (AV) shunt
in his right arm. Which of the following actions should the nurse take?
o Give IV fluids through the AV shunt
o Obtain blood pressure from the right arm
o Check a bruit over the shunt on a regular basis
o Avoid range of motion in the right arm
•A nurse is caring for a client who has been admitted to the mental health
unit. While reinforcing teaching about the client’s prescribed exacerbations,
thenursecommunicatestruthfullyabouttheadverseeffectsofthemedications.
Which of the following ethical concepts is the nurse exhibiting?
o Veracity
o Autonomy
o Justice
o Beneficence
•A nurse is caring for a client who is postoperative following a subtotal
thyroidectomy.Thenurseshouldplacetheclientinwhichofthefollowing
positions?
o Dorsal recumbent
o Left lateral
o Semi-fowler’s
o Supine
•A nurse is reinforcing teaching with the parents of a child who has a new
diagnosisofWilmstumor.Whichofthefollowinginterventionsshouldthe
nurse include in theteaching?
o “You should not palpate your child’s abdomen prior to surgery.”
o “You should give your child captopril 200 mg PO daily.”
o “Your child should have surgery in 7 to 10 days to remove the tumor.”
o “Your child will not require further treatment after removal of the
tumor.”
•A nurse enters the room of a school-age child and finds him on the floor
experiencingatonic-clonicseizure.Whichofthefollowingactionsshould
the nurse take?
o Place a pillow under the child's head
o Restrain the child’s upper extremities
o Place a padded tongue blade in the child’s mouth
o Turn the child onto his back
•A nurse is contributing to the plan of care for a client who is to begin
receiving intermittententeralfeedings.Whichofthefollowingactions
should the nurse recommend?
o Place the client in high-fowler’s position during feedings
o Dilute the formula with water for the first 24 hr of therapy
o Check the clients gastric residual 15 min after each feeding
o Chill the formula before initiating feedings
•Anurseiscollectingdatafromaclientinanoutpatientclinicand
observesextensivebruisingontheclient’sarms.Thisnursesuspects
the client is experiencing intimate partner abuse. Which of the
following is the nurse’s priority action?
o Provide information about moving to a shelter
o Offer support and create a safe, trusting environment
o Document the client’s injury and include a photograph
o Determine if there is a gun in the client’s home
•A nurse in an urgent care clinic is caring for a client who reports recently
usingmethylenedioxy-methamphetamine.Whichofthefollowingfindings
should the nurse expect?
o Hypothermia
o Somnolence
o Muscle weakness
o Hallucinations
•A nurse is reinforcing teaching with a client who has a prescription for
ferroussulfateelixir.Whichofthefollowing statementsbytheclient
indicates an understanding of the teaching?
o I will report black stools to mydoctor
o I will mix the medication with water
o I can prevent constipation if Idrink moremilkwhiletaking this
medication
o I can prevent nausea if I take the medication on an empty stomach
•A nurse is collecting data from a client who received oxytocin 10 units IM 30
minagoforexcessivevaginalbleeding.Whichofthefollowingfindings
should the nurse expect?
o Client report of burning with urination
o Client report of uterine cramping
o Boggy fundus 3 fingerbreadths above the umbilicus
o Saturation of perineal pad
in 15 min 114.
•A nurse is attending an educational workshop about client confidentiality. Which
ofthefollowingactions b ythe nurseindicates an understanding ofthe
teaching?
o Changes her personal login password at random intervals
o Gathers data from clients on other units who have the same diagnosis
o Uses a personal digital assistant to record client information
o Disables the use of the speed-dial function on fax machines
•Anurse isassisting with discharge planningforagroupof clients.Which
ofthefollowingclients shouldthenurserecommendahomehealth
referral?
o A young adult client who has a substance abuse disorder
o An older adult client who has heart failure and lives alone
o A middle adult client who had a mastectomy and requires
chemotherapy
o An adolescent client who has a tibia fracture and requires crutches
•Anurseisreinforcing teachingwithafemaleclient whoistakingphenytoin.
Which of the following instructions should the nurse include in the
teaching?
o You can safely take this medication if you become pregnant
o You can skip a dose of this medication if you are nauseated
o You might experience swollen gums while taking this medication
o Youshouldexpect tohave bloodwork every 6monthswhiletaking
this medication
•A nurse is preparing to administer paroxetine 15 mg PO oral suspension to a
client who has a depressive disorder. The amount available is 10 mg/ 5 mL.
How many mL should the nurse administer?(Round answer to the nearest
tenth.)
•
•A nurse is reinforcing teaching with a client who is at 38 weeks of gestation
and is to undergo a contraction stress test. Which of the following statements
by the client indicates an understanding of the teaching?
o I am having this test to check if my baby’s lungs are mature
o The nurse will draw my blood after the procedure
o I am having this test because my baby
nonstress test
o I will need to fast for 6 hours prior to the procedure
•A nurse is discussing health practices with the mother of a toddler who is from
adifferentculturalbackgroundthanthenurse.Whichofthefollowingstatements
by the mother indicates that she practices cupping?
was not reactive during a
7.5 mL
o I apply petroleum jelly with garlic along my child’s wrist to treat
infections
o I insert needles into meridian lines of my child’s body to help with
pain relief
o I rub the edge of a coin lengthwise on my child’s back when he is sick
o I sometimes place a bottle containing steam against my child’s skin
•Anurseisreinforcingteachingwithaclientwhohasprimaryopen-angle
glaucoma and has a prescription for timolol eye drops. Which of the
following statements by the client indicates an understanding of the
teaching?
o I should take a zinc supplement while taking this medication
o This medication will dilate my eyes
o I should check my heart rate while taking this medication
o This medication will darken the color of my eyes
•Anurseiscollectingdatafromapreschoolerwhohasseveredehydration.
Which of the following findings should the nurse expect?
o Jugular vein distention
o Moist mucous membranes
o Weight loss of 10%
o Capillary refill of 2 seconds
•A nurse is contributing to the plan of care for an older adult client. Which
of the following physiological changes should the nurse consider when
administering medication?
o Decreased liver function
o Decreased kidney function
o Increased metabolism
o Decreased pulmonary function
•A nurse is caring for a client who is taking multiple medications and asks
aboutpossibleinteractions.Towhichofthefollowingmembersofthe
interdisciplinary team should the nurse make a referral?
o Social worker
o Advanced practice nurse
o Patient care technician
o psychologist
•A nurse is collecting data from a client who just received his first dose of
sulfasalazine to treat ulcerative colitis. Which of the following findings should the
nurseidentifyasanindicationofanallergicreactiontothismedication?
o Arthralgia
o Fever
o Dyspnea
o Nausea
•A nurse is collecting nutritional data from agroup of adult clients. For
whichofthefollowingclientsshouldthenurserecommendan
interprofessional care conference with a dietician?
o A client who has a body mass index of 32
o A client who has a sodium intake of 1200 mg/day
o A client who has a total fat intake of 25% of daily calories
o A client who has a serum albumin level of 4.5 g/dL
•A charge nurse is reinforcing teaching with a newly licensed nurse about
infection control measures. Which of the following statements by the
newly licensed nurse indicates an understanding of the teaching?
o Soiled dressings should be placed in a biohazard trash receptacle
o DropletprecautionsrequirethatIwearagownandgloveswhen
providing care
o Following a blood spill, I should use a bleach solution with a ratio of
1 to 20
o Foraclient whohas Clostridium difficile, Iwillcleanmy hands
with an alcohol-based rub
•A nurse is preparing a vitamin K injection to give to a newborn. The
newborn’s mother questions the purpose of this medication. Which of the
following responses should the nurse make?
o This medication will decrease the risk of hemorrhage in your newborn
o This medication will increase the immunity of your newborn
o This medication will increase the absorption of nutrients in theintestines
o This medication will decrease the possibility of your newborn developing
jaundice
•Anurseiscollectingdatafromaclientwhohasdiabeticketoacidosis.
Which of the following findings should the nurse report to the
provider?
o Fruity breath odor
o Elevated blood pressure
o Clammy skin
o Bounding pulse
•A nurse is caring for a client who has a vacuum-assisted closure
system to treat a pressure ulcer. Which of the following actions
should the nurse take?
o Cover the wound with a transparent film extending outward 5 cm (2
in)
o Replace the wounds dressing every 12 hr
o Use an adhesive remover to remove tape before reapplying a dressing
o Pack the wound tightly with sterile gauze
•A nurseis verifyinginformed consent for aclient who ispreoperative
for a vaginal hysterectomy. Which of the following statements should
the nurse identify as an indication that the client has given
informed consent?
o I should expect my periods to resume in 1 month
o I am thankful I am done having children
o I will have a large scar on my stomach after this procedure
o I will no longer need a regular gynecological examination
•A nurse is caring for aclient who is experiencing a tonic-clonic seizure.
Which of the following actions should the nurse take?
o Measure the duration of the seizure
o Restrain the clients arms and legs to prevent injury
o Lower the side rails of the bed when the seizure begins
o Insert an oral airway into the clients mouth
•A nurse is collecting data from a client who is at 12 weeks of gestation. The
clientstates,“We'vebeentryingtogetpregnantforseveralmonths,but
now I'm notso sureI'm ready.”Which of the followingresponses should
the nurse make?
o I wouldn’t worry about it if I were you. You’ll be a good mother
o You need to talk to a therapist about how you’re feeling
o Why do you feel that way if you’ve been trying to get pregnant
o Many women experience feelings of ambivalence duringpregnancy
•Anurse iscaringfor fourclients. Which of the following situations
require a signed consent form?
o Performing a wound irrigation with an antibiotic solution
o Giving a haemophilus influenzae B vaccine to an infant
o Administering an iron injection Z-track method
o Inserting a nasogastric tube
•A nurse is receiving a report on four clients. The nurse should plan to collect
data from which of the following clients first?
o A preschooler who has epiglottis and is drooling
o An adolescent who is postoperative and requesting pain medication
o An infant who is dehydrated and has a heart rate of 160/min
o A school-age child who has a broken ankle and reports pruritus
under his cast
•Anurse iscaring for aclient who reports frequent headaches after
takingchewableisosorbidedinitrate.Whichofthefollowing
statements should the nurseinclude?
o The headaches should decrease as you get used to the medication
o Swallow the tablet whole to minimize your headaches
o Youshouldtakethemedicationonan emptystomachto
prevent a headache
o You can’t discontinue the medication until the
headache goes away 137.
•A nurse is implementing a bladder training program for a client who had a
stroke.Whichofthefollowinginterventions shouldthenursetake?
o Offer toileting every 6 hr
o Encourage intake of caffeinated beverages
o Limit fluid intake to 1500 mL a day
o Check for residual urine after voiding
•A nurse is contributing to the plan of care for a client who is pregnant and
reports having trouble sleeping. Which of the following instructions should
the nurse include in the plan of care?
o Use a transcutaneous electrical nerve stimulator
o Soak in a bathtub of hot water each night
o Obtain a prescription for pramipexole
o Lie on your left side with your top leg forward
•Anurse isreinforcing teaching with a client who has anew prescription
foramitriptyline.Whichofthefollowingfindingsshouldthenurse
include in the teaching as an adverse effect of this medication?
o Increased salivation
o Orthostatic hypotension
o Alopecia
o P
ol
y
u
ri
a
1 4 1 .
•A nurse iscontributing totheplan of carefor aclient who hasmajor
depressive disorder. Which of the following recommendations should the
nurse include in the plan of care?
o Suggest the client exercise before going to bed
o Recommend the client spend time alone in his room
o Encourage the client to use positive self talk
o Offer the client low-protein snacks throughout the day
•A nurse is preparing to administer ibuprofen solution 60 mg orally to a 7
montholdinfantwhoisfebrile.Availableisibuprofen50mg/1.25mL.
How many mL should the nurse administer?
•1.5 mL
•A nurse is caring for a child who has terminated cancer. Which of the
followingresponsesbythechild’sschool-agebrothershouldthe
nurse expect ?
o Believes that his brother’s death will be reversible
o Alternates himself from his peers
o Believes his bad behavior is causing his brother’s death
o Regresses to an earlier developmental level
•A nurse is caring for a client who is experiencing alcohol withdrawal.
Which of the following medications should anticipate administering to prevent
complications ofwithdrawal?
o Lorazepam
o Methimazole
o Potassium
o Naloxone
•AnurseisreinforcingdietaryteachingwithaclientwhoseprepregnancyBMI
was
30.5. The nurse should recognize that the client understands theteaching
whenshe statesthat she should expect togain howmany pounds
during her pregnancy?
o 32 lb
o 24 lb
o 8 lb
o 16 lb
•A nurse is assisting with the care of a client following electroconvulsive
therapyforthetreatmentofadepressivedisorder.Whichofthefollowing
findings should the nurse expect 15 min following this procedure?
o Paraesthesias
o Tonic-clonic seizures
o Disorientation
o Sleep apnea
•Anurse iscaringfor anadolescent client who hasbulimianervosa. Which
of the following actions should the nurse take first?
o Instruct the client about effective coping strategies
o Suggest that the client assist with meal planning
o Observe the client during and after meals
o Refertheclient toasupport group for adolescentswho have
eating disorders
•A nurse is monitoring a client who is postoperative. Which of the following
actionsshouldthenursetakewhencollectingdataabouttheclient's
respirations?
o Inform the client when beginning to observe the respirations
o Count the client's respirations for 15 seconds
o Place the client in a supine position
o Observe the movements of the client’s chest wall
•A nurse is preparing to give change-of-shift report on a client who is 2 days
postoperative following a total knee arthroplasty. Which of the following information
about the client should the nurse include in the report?
o Steps required for dressing change
o Admission vital signs
o Preferred bath time
o Time of last pain medication
•A nurse is reinforcing discharge teaching with a client who has a bipolar
disorderandanewprescriptionforcarbamazepine.Whichofthefollowing
statementsbytheclientindicatesanunderstandingoftheteaching?
o I will plan to increase my intake of green, leafy vegetables
o I should follow a gluten-free diet while taking this medication
o I should take this medication on an empty stomach
o I will plan to avoid grapefruit juice while taking this medication
•An assistive personnel tells the charge nurse that her assignment is too
demanding. She angrily tells the nurse to reassign one of her tasks to
another AP. Which of the following actions should the nurse take to
resolve the conflict?
o Grant the AP’s request to reassign the task
o Ask the AP to discuss the issue in a private area
o Perform the tasks personally rather than reassigning them
o Reprimand the AP for failure to perform the tasks
•Anurse isreinforcingteachingwithaclient who hasarthritis.Which
of the following instructions should the nurse include in the
teaching?
o Engage in low-impact aerobic exercises
o Apply ice to the inflamed joint
o Sleep on a soft mattress
o Use fingers to push off from the bed or chair
•A nurse is caring for a female client who has an indwelling catheter
withaurinarydrainagesystem.Whichofthefollowingactions
should the nurse take?
o Collect a sterile specimen from the urinary drainage bag
o Secure the tubing with adhesive tape to the lower abdomen
o Instruct the client tohold the drainage bag at waist height
when ambulating
o Coil the tubing on the bed above the collection bag
•A nurse is assisting with a support group for clients who have
experienced intimate partnerviolence.The nurse should identify which
of the following client statements as indicating the greatest risk for
violence?
o I am going to get a job to make some extra money
o I plan to visit my friends while my husband is at work
o I have decided to tell my husband I am leaving him
o I just got accepted to our local college
•A nurse is collecting data from a client who is receiving magnesium
sulfate viacontinuous IV infusion for preterm labor. Which ofthe following
findings should the nurse expect?
o Tachypnea
o Tachycardia
o Hypotension
o Hyperthermia
•A charge nurse working in a long-term care facility overhears two AP’s in
the nurses stations discussing a client who was just admitted. Which of the
following actions should the charge nurse take?
o Inform the client of the AP’sactions
o Tell the APs to stop the conversation
o Document the event in the client’s progress notes
o Submit an incident report to the risk manager
•A nurse is reinforcing teaching with a client who is scheduled for
an intravenous pyelogram. Which ofthe following statementsmade by
the client indicates an understanding of theteaching?
o I do not need to sign a consent form before this procedure
o I will feel a warming sensation after the injection of the dye
o I can have a meal up to 2 hours before the procedure
o I should limit my fluid intake for 2 days after the procedure
•A nurse is assisting with the plan of care for a client who has endstage amyotrophic lateral sclerosis and has developed pneumonia.
Which of the following actions should the nurse take?
o Initiate a referral to a speech therapist
o Request a prescription for a glutamate antagonist
o Verify the status of the client’s advance directive
o Suggest a genetic counseling for the client’s family
•Anurseisreinforcingteachingwithanewmotheronfacilitysecurity
measures.Whichofthefollowingstatementsbythemotherindicatesan
understanding of the teaching?
o I can take my baby to the lobby to visit family
o I will carry my baby to the nursery
o I can remove my security band to give it to a family member
o I will have an identification band that matches the one my baby wears
•A nurse is caring for a client who is 2 days postoperative following a
total bilateral mastectomy. The client is tearful and looks away when her
surgicaldressingsareremoved.Thenurseshouldplacethepriorityaction
on which of the following actions?
o Providing the client with information on community resources thatwill
strengthen her coping skills
o Identifying the client’s perception of the changes in her physical appearance
o Demonstrating a nonjudgmental attitude toward the client when providing
care for her surgical wounds
o Encouraging the client to write about her feelings in a journal each
day
•Anurseisreinforcingteachingwithaclientwhoisatriskforhypertension.
Whichofthefollowingriskreductionstrategiesshouldthenurseincludein
the teaching?
o Increase dietary intake of canned vegetables
o Limit caloric intake to 2500 calories per day
o Restrict alcohol intake to 360 mL (12 oz) of wine per day
o Walk for 30 min 5 days per week
•Anurse iscaringforaclientwhohasdependent personalitydisorder.
Whichofthefollowingmanifestationsshouldthenurseexpect?
o Reclusive
o Perfectionistic
o Submissive
o Impulsive
•A nurse is assisting with the admission of a client who has varicella zoster.
Which of the following interventions should the nurse plan to
implement?
o Assign the client to a positive-airflow room
o Have visitors remain at least 0.91 m (3 feet) away from the client
o Administer aspirin if the client develops a fever
o Initiate contact precautions for the client
•A nurse is planning to administer four different medications to a client
viagastrostomytube. Whichofthefollowing actionsshouldthenurse
take?
o Let timed-release medications dissolve for 30 min prior to administration
o Mix crushed medications in 20 mL of water
o Flush with 10 mL of tap water after administration
o Allow separate medications to flow through the tube by gravity
•A nurse is preparing to administer medications to a client who has pneumonia
andisondropletprecautions.Whichofthefollowingsuppliesshouldthenurse
use while caring for thisclient?
o Surgical mask
o Gown
o Sterile gloves
o N95 respirator
•A nurse is reinforcing dietary teaching with a client who is at
riskfor cardiovasculardisease.Whichofthefollowingstatements by
the client indicates an understanding of the teaching?
o I drink whole milk everyday
o I may have four egg yolks per week
o I make toast using enriched white bread
o I have unsalted pretzels for a snack
•A nurse in an inpatient psychiatric unit is caring for a client who was raised
inanAsian culture. Which ofthe following communication techniques by
the nurse demonstrates culturalsensitivity?
o Sitting closer than an arm’s length
o Patting the clients shoulder for reassurance
o Using social conversation to fill periods of silence
o Holding eye contact for brief instances
•Anurseisreinforcingteachingaboutsafefoodhandlingwithaclient
whoisrecoveringfromfoodpoisoning.Whichofthefollowing
statements by the client indicates an understanding of the
teaching?
o I will set my refrigerator to 50 degrees fahrenheit
o I will be sure to cook chicken to 180 degrees fahrenheit
o It is safe to eat unpasteurized dairy products
o Itis safe touse uncooked ground beef that has been refrigerated
for 4 days
•A nurse is assisting with the discharge plan for a client who has burns on his
arms and hands. Which of the following referrals should the nurse
recommend to improve the client’sADL’s?
o Social worker
o Occupational therapist
o Case manager
o Registered dietician
•Anurseisassistingwithaprenatalexaminationofaclientwhoisat8
weeksofgestation.Thenursenotesthattheclientsvaginaandvulva
areapurplishcolor.Thenurseshoulddocument thisfinding aswhich
of the following?
o Chadwick’s sign
o Hegar's sign
o Chloasma
o Ballottement
•Anurseshouldrecognizethataclient'sright toconfidentialityhasbeen
breached when which of the following occur?
o A nurse tells the chaplain that her assigned client has a new diagnosis of
cancer
o A social worker reads a client's chart as a follow-up to a
requested consultation
o A facility risk manager includes information from a client's medicalrecord
in a written report
o A newly licensed nurse discusses his clients postoperative
complications during shift report
•Anurse on amedical-surgery unit is preparing to assist with the admission of
clients who were injured in a tornado. Which of the following clients
should the nurse recommend for discharge to make room for the new
admissions?
o A client who had a lobectomy and has a chest tube drainage system
o A client who had a radical mastectomy 36 hr ago and has a surgical drain
o A client who has cervical cancer and an internal radioactive implant
o Aclient whohadacerebrovascular accident 8hragoand
received thrombolytic therapy
•A nurse is reviewing laboratory values for a client who has respiratory
acidosis.Whichofthefollowingarterialbloodgasvaluesshouldthe
nurse expect?
o pH 7.45, PaCO2 35 mm Hg
o pH 7.35, PaCO2 52 mm Hg
o pH 7.28, PaCO2 28 mm Hg
o pH 7.30, PaCO2 50 mm Hg
•A nurse is caring for a client who is receiving oxygen when a fire starts
in an adjacent room. Identify the sequence of actions the nurse
should take. (Move steps in order)
•Move the
client to a
safe location
2. Pull the
nearest fire
alarm
•Shut all
doors
and
window
s 4.
Attempt
to
extingui
sh the
fire
•A nurse is caring for a client who is receiving morphine for pain. Which of
the following findings indicate that the client is experiencing an adverse
effect of the medication?
o Lacrimation
o Hypertension
o Urinary retention
o Tachycardia
•Anurseisreinforcingdietaryteachingwithaclientwhohascholecystitis.
Whichofthefollowingfoodchoicesshouldindicatethattheclient
understands the teaching?
o Peanut butter
o Dark chocolate
o Cream of potato soup
o Skim milk
•A nurse is caring for a client who has a new mastectomy. Which of
the following statements bythe client should indicate tothe nurse that the
client is beginning to cope with the changes in her body image?
o I am afraid to discuss my concerns with my husband
o I am angry i had to lose my breast
o I am worried i will never be able to take care of myself
o I am not ready to change my own dressing
•A nurse is caring for an adult client who reports having trouble getting to
sleepatnight.Whichofthefollowingrecommendationsshouldthe
nurse make?
o Establish a daily exercise routine
o Keep the telephone volume low while you are trying to fall asleep
o Remain in bed until you fall asleep
o Sleep longer hours on the weekend
•A nurse is caring for an adolescent that states, “I joined the track and field
team,soIwon'targuewithmybrothersanymore.”Thenurseshouldidentify
that the client is using which of the following defense mechanisms?
o Regression
o Repression
o Denial
o Sublimation
•A nurse is reinforcing teaching with a client who has a new prescription
for transdermalnitroglycerin patches.Whichofthefollowingstatements
by the client indicates an understanding of thismedication?
o I will replace the patch every 12 hours
o I will apply the patch in the same place every day
o I will place the patch on a hairless area of skin
o I will remove the patch if i develop a headache
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