ATI RN Comprehensive Predictor Form A, B, C, AND ATI COMPREHENSIVE EXIT FINAL. 125 Pages

ATI RN Comprehensive Predictor Form A 1. A nurse in a pediatric unit is preparing to insert an IV catheter for 7-year- old. Which of the following actions should the nurse take? 2. A nurse is caring for a client wh ...

ATI RN Comprehensive Predictor Form A 1. A nurse in a pediatric unit is preparing to insert an IV catheter for 7-year- old. Which of the following actions should the nurse take? 2. A nurse is caring for a client who has arteriovenous fistula Which of the following findings should the nurse report? 3. A nurse is providing discharge teaching for a client who has an implantable cardioverter defibrillator which of the following statements demonstrates understanding of the teaching? 4. A nurse is caring for a client who is at 14 weeks gestation and reports feelings of ambivalence about being pregnant. Which of the following responses should the nurse make? 5. A nurse is planning care for a client who has a prescription for a bowel- training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care? 6. A nurse is caring for a client who is in active labor and requests pain management. Which of the following actions should the nurse take? 7. a nurse in an emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority? 8. a nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include? 9. A nurse is teaching an in-service about nursing leadership. Which of the following information should the nurse include about an effective leader? 10. A nurse is reviewing the laboratory findings of a client who has diabetes mellitus and reports that she has been following her (unable to read) care. The nurse should identify which of the following findings indicates a need to revise the client’s plan of care. 11. A nurse in a provider’s office is reviewing the laboratory results of a group of clients. The nurse should identify that which of the following sexually transmitted infections is a nationally notifiable infectious disease that should be reported to the state health department? 12. A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. Which of the following group facilitation techniques should the nurse include in the teaching? 13. A nurse is planning for a client who practices Orthodox Judaism. The client tells the nurse that (Unable to read) Passover holiday. Which of the following action should the nurse include in the plan of care? 14. A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the effectiveness of the treatment 15. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets (Unable to read) a respiratory rate of 10/min. After securing the client’s airway and initiating an IV, which of the following actions should the nurse do next. 16. A nurse in an emergency department is caring for a client who reports cocaine use 1hr ago. Which of the following findings should the nurse expect? 17. A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl. Which of the following manifestations should the nurse expect? 18. A nurse in a pediatric clinic is reviewing the laboratory test results of a school age child. Which of the following findings should the nurse report to the provider? 19. A charge nurse is teaching a newly licensed nurse about clients designating a health care proxy in situations that require a durable power of attorney for heal care (DPSHC). Which of the following information should the charge nurse include? 20. A nurse in the PACU is caring for a client who reports nausea. Which of the following actions should the nurse take first? 21. A nurse is caring for a client who has a history of depression and is experiencing a situational crisis. Which of the following actions should the nurse take first? lar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following should the actions should the nurse take? 23. A 24. A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the (Unable to read) unit due to a staffing shortage. Which of the following client should the nurse delegate to the LPN? 25. A nurse is working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan? 25. A nurse is caring for a client who is dilated to 10 cm and pushing. Which of the following pain-management (Unable to read) a safe option for the client? 26. C 27. A nurse is assessing a client who has major depressive disorder. Which of the following findings should the nurse identify as the (Unable to read) (Most important?) 28. A nurse is providing teaching about immunizations to a client who is pregnant. The nurse should inform the client that she can receive which of the following immunizations during pregnancy? (Select all that apply) 29. A nurse is caring for a client who has end-stage kidney disease. The client’s adult child asks the nurse about becoming a living kidney donor for her father. Which of the following condition in the child’s medical history should the nurse identify as a contraindication to the procedure? 30. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian 31. A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make? 31. A nurse is assessing a child who is being treated for bacterial pneumonia. The nurse notes an increase in the child’s glucose. The nurse should identify this finding as an adverse effect of which of the following medications 2. The nurse is providing teaching about folic acid to a client who is prima gravida. Which of the following information should the nurse include in the teaching? 33. A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse’s priority? A. Social relationship with peers. B. Plans for attending school while pregnant. C. (Unable to read) (Picked this one) Medicaid? D. Understanding of infant care. 34. A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse include? A. Critical pathways have unlimited timeframe for completion B. (Unable to read) decrease health care costs. C. (Unable to read) critical pathway if variances (Unable to read) D. (Unable to read) are used to create the critical pathway. 35. A nurse is reviewing the medical record of a client who has schizophrenia. Which of the following should the nurse report to the provider? Exhibit 1 Blood pressure: 102/56 mm Hg. Heart rate: 95/min Respiratory rate: 18/min Temperature: 37.4C (99.3F) Exhibit 2 Medication Administration Record Clozapine 150 mg PO twice daily Benztropine 0.5 mg PO twice daily as needed for tremors. Exhibit 3 Nurse’s notes: Client reports feeling dizzy when changing positions, Reports weight gain of 1kg (2.2 lb.) in the past month. Also reports a sore throat for the past 3 days and dry mouth. Client ate 75% of breakfast and reports slightly nauseous. A. Dietary intake B. Heart rate. C. Sore throat. D. Blood pressure. 36. A charge nurse is educating a group of unit nurses about delegating client tasks to assistive personnel A. “The nurse is legally responsible for the actions of the AP”. B. “An AP can perform tasks outside of his range if he has been trained”. C. “An experienced AP can delegate to another AP”. D. “An RN evaluates the client needs to determine tasks to delegate” 37. A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider? A. Contractions lasting 80 seconds B. FHR baseline 170/min C. Early decelerations in the FHR D. Temperature 37.4C (99.3) 38. A nurse working in a rehabilitation facility is developing a discharge plan for a client who has left-sided hemiplegia the following actions is the nurse’s priority? A. Consult with a case manager about insurance coverage. B. Counsel caregivers about respite care options. C. Ensure that the client has a referral for physical therapy. D. Refer the client to a local stroke support group. 39. A nurse in a mental health unit is planning room assignments for four clients. Which of the following client should be closest to the nurse’s station? A. A client who has an anxiety disorder and is experiencing moderate anxiety. B. A client who has somatic symptom disorder and reports chronic pain. C. A client who has depressive disorder and reports feeling hopeless. D. A client who has bipolar disorder and impaired social interactions. 40. A nurse is preparing to measure a temperature of an infant. Which of the following action should the nurse take? A. Place the tip of the thermometer under the center of the infant’s axilla. B. Pull the pinna of the infant’s ear forward before inserting the probe. C. Insert the probe 3.8 cm (1.5in) into the infant’s rectum. D. Insert the thermometer in front of the infant’s tongue. 41. A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan? A. Encourage the client to spend time in the day room B. Withdraw the client’s TV privileges is the does not attend group therapy C. Encourage the client to take frequent rest periods D. Place the cline in seclusion when he exhibits signs of anxiety 42. A nurse is admitting medications to a group of clients. Which of the following occurrences requires the completion of an incident report? A. A client receives his antibiotics 2hr late B. A client vomits within 20min of taking his morning medications C. A client requests his statin to be administered at 2100 D. A client asks for pain medication 1hr early 43. A nurse is caring for a client who is 24 hr. postpartum and is breast feeding her newborns. The client asks the nurse to warm up seaweed soup that the client’s partner brought for her. Which of the following responses should the nurse make? A. “Does the doctor know you are eating that?” B. “Why are you eating seaweed soup?” C. “Of course I will heat that up for you” D. “The hospital good is more nutritious” 44. 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 nasogastric tube clamped after administering oral medication B. Documenting communication with a provider in the progress notes of the client’s medical records C. Administering potassium via IV bolus D. Placing a yellow bracelet on a client who is at risk for falls 45. a nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching? A. Establish a toileting schedule for the client B. Use clothing with buttons and sippers C. Discourage physical activity during the day D. Engage the client in activities that increase sensory stimulation 46. The nurse is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client’s history is a contradiction to the use of oral contraceptives? A. Hyperthyroidism. B. Thrombophlebitis. C. Diverticulosis. D. Hypocalcemia. 47. A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations. The client states, “It’s hard not to listen to the voices.” Which of the following questions should the nurse ask the client? A. “Do you understand that the voices are not real?” B. “Why do you think the voices are talking to you?” C. “Have you tried going to a private place when this occurs?” D. “What helps you ignore what you are hearing?” 48. A charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following should the nurse include in the teaching? A. Placing a belt restraint on a school-age child who has seizures. B. Securing wrist restraints to the bed rails for an adolescent. C. Applying elbow immobilizers of an infant receiving cleft lip injury D. Keeping the side rails of a toddler’s crib elevated. 49. B 50. A nurse is preparing to mix NPH and regular insulin in the same syringe. Which of the following A. Inject air into the NPH insulin vial. B. (Unable to read) C. Withdraw the prescribed dose of regular insulin D. Withdraw the prescribed dose of NPH insulin 51. a Nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? A. “Let’s talk about how you can change your response to stress.” B. “We should establish our roles in the initial session.” C. “Let me show you simple relaxation exercises to manage stress.” D. “We should discuss resources to implement in your daily life.” 51. A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella rooster. Which of the following information should the nurse include? A. Children who have varicella are contagious until vesicles are crusted. B. Children who have varicella should receive the herpes zoster vaccination. C. Children who have varicella should be placed in droplet precaution. D. Children who have varicella are contagious 4 days before the first vesicle eruption. 52. A staff nurse is observing a newly licensed nurse suction a client’s tracheostomy. Which of the following requires intervention by the staff nurse? A. Waits 2 minutes between suctions. B. Encourages the client to cough during suctioning. C. Apply suctioning for 15 seconds. D. Inserts the catheter without applying suction. 53. A nurse is teaching at a community health fair about electrical fire prevention. Which of the following information should the nurse include in the teaching? A. Use three pronged grounded plugs. B. Cover extension cords with a rug. C. Check the tingling sensations around the cord to ensure the electricity is working. D. Remove the plug from the socket by pulling the cord. 54. A nurse is providing care for a group of clients. Which of the following client’s should the nurse identify as having the highest risk for developing a pressure injury? A. A client who has a T-tube following an open cholecystectomy. B. A client who had a knee 2 days ago following a sports injury. C. A client who has dementia and is incontinent of urine and feces D. A client who has a myocardial infarction and is receiving thrombolytic therapy. 55. A nurse is teaching a client who has glaucoma and a new prescription for timolol eyedrops. Which of the following statements indicates an understanding of the teaching? A. “I will place the eye drops in the center of my eye” B. “I will place pressure on the corner of my eye after using he eye drops” C. “I should expect my tears to turn a red color after using the eye drops.” D. “I should expect the eye drops to appear cloudy.” 56. A nurse is providing teaching to a client who is 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? A. Bleeding gums B. Faintness upon rising C. Swelling of the face D. Urinary frequency 57. A nurse is caring for a client who has a diagnosis of stage IV metastatic cancer. Which of the following responses should the nurse make? A. “I would recommend sharing your feelings with a psychologist”. B. “I can give you information about making end of life decisions”. C. “You should discuss your end life decisions with your family” D. “Everyone feels this way at first. You will start feeling better soon”. 58. A nurse is caring for a client wo has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take? A. Keep client’s calcium gluconate at the client’s bedside B. Monitor blood pressure every 2 hr. C. (Limit or remove?) IV bag from exposure to light. D. Attach tan inline filter to the IV tubing. 59. A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect? A. Feelings of dread B. Heightened perceptual field C. Rapid speech D. Purposeless activity 60. A nurse is reviewing the laboratory report of a client who has been having lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect? A. Withhold the next dose. B. Increase the dosage. C. Discontinue the medication. D. Administer the medication. 61. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? A. Stay in bed at least 1hr if unable to fall asleep B. Take 1 hr nap during the day C. Perform exercise prior to bed D. Eat a light snack before bedtime 62. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer? A. Pregabalin B. Lorazepam C. Colchicine D. Codeine. A. nurse is caring for a client following insertion of a chest tube 12 hr. ago. The (Unable to read) following actions should the nurse take? A. Assess the amount of drainage in the collection chamber. B. Clamp the chest tube during ambulation. C. Report continuous bubbling in the water seal chamber. D. Strip the chest tube every 4 hr. to maintain patency. 64. A nurse is caring for a client who is receiving morphine 4 mg via IV bolus every 4 hr. PRN. The nurse should monitor for which of the following adverse effects? A. Productive cough. B. Urinary retention. C. Rhinitis D. Fever. 65. A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states “I don’t know what to do. Everything has been happening so quickly.” Which of the following by the nurse is therapeutic? A. “Can you talk about what happens with your partner at home?” B. “Why do you think your partner’s symptoms are progressing so quickly?” C. “You should make sure your partner takes the prescribed medication.” D. “You did the right thing by bringing your partner in for treatment.” 66. A nurse is providing dietary teaching to a guardian of a preschooler who has a new diagnosis of celiac disease. Which of the following statements by the guardian indicates an understanding of the teaching? A. “I will put my child on a gluten-free diet”. B. “I will administer digestive enzymes with meals and snacks”. C. “Provide my child with some high fiber foods.” D. “I will give my child whole wheat toast and milk for breakfast”. 67. A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take? A. Prime IV tubing with 0.9% sodium chloride. B. Use a 24-gauge IV catheter C. Obtain filter less IV tubing. D. Place blood in the warmer for 1 hr. 68. A nurse is admitting a client who has diabetic ketoacidosis. Which of the following types of continuous infusions should the nurse initiate? A. 0.9% normal saline. B. NPH insulin. C. Glargine insulin. D. 0.45% saline. 69. A nurse is teaching who has chronic pain about avoiding constipation from opioid medications. Which of the following should the nurse include in the teaching? A. Drink 1.5L fluids each day. B. Take mineral oil at bedtime. C. Increase exercise activity D. Decrease insoluble fiber. 70. A nurse is teaching about preventative measures to a female client who has chronic urinary tract infections. Which of the following interventions should the nurse include in the teaching? A. “Drink 2 liters of warm water per day”. B. “Empty your bladder every 6 weeks.”. C. “Soak in a warm bath everyday”. D. “Take an oral estrogen tablet”. 71. 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. A client who has sinus arrhythmia and is receiving monitoring B. A client who has a hip fracture and a new onset of tachypnea C. A client who has epidural analgesia and weakness in the lower extremities D. A client who has diabetes and a hemoglobin A1C of 6.8% 72. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include? A. Consume food high in bran fiber B. Increase intake of milk products C. Sweeten foods with fructose corn syrup D. Increase foods high in gluten 73. A nurse is caring for a 1-day-old newborns who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take? A. the infant 30 ml (1 oz) glucose water every 2 hr. B. Keep the infants head covered with a cap. C. Ensure that the newborn wears a diaper. D. Apply lotion to the newborn every 4 hr. 74. a nurse is teaching a group of newly licensed nurses about client advocacy. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? A. “(Unable to read) I feel to be in his best health care decision” B. “I will intervene if there is conflict between a client and his provider” C. “I should not advocate for a client unless he is able to ask me himself” D. “I will inform a client that his family should help make his health care decisions.” 75. A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take? A. Raise the side rails on both sides of the client’s bed during repositioning. B. Reposition the client without assistive devices. C. Discuss the client’s preferences for determining a reposition schedule. D. Evaluate the client’s ability to help with repositioning. 76. A 77. A nurse is caring for an infant who has coaction of the aorta. Which of the following should the nurse identify as an expected finding? A. Weak femoral pulses B. Frequent nosebleeds C. Upper extremity hypotension D. Increased intracranial pressure\ 78. a nurse is auscultating for crackles on a client who has pneumonia. Which of the following anterior chest wall locations should the nurse auscultate? 78. A nurse is assisting with the development of an informed document for participation in a research study. Which of the following information should the nurse include? A. A statement that participants can leave the study at will. B. An assignment of the participant to either the experimental or control group. C. A list of the clients participating in the study. D. A description of the framework the researchers will use to evaluate the data. 79. A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include? A. Excessive sweating B. Increased urinary frequency C. Dry cough D. Metallic taste in mouth 80. A nurse is caring for a client who has a new temporary synchronous pacemaker. Which of the following should the nurse report to the provider? A. The client’s pulse oximetry level is 96%. B. (Unable to read) C. The client develops hiccups. D. The ECG shows pacing spikes after the QRS complex. 81. A nurse is preparing discharge information for a client who has type 2 diabetes mellitus. Which of the following resources should the nurse provide to the client? A. Personal blogs about managing the adverse effects of diabetes medications B. Food label recommendations from the Institute of Medicine C. Diabetes medication information from the Physicians’ Desk Reference D. Food exchange lists for meal planning from the American Diabetes Association 82. A nurse is providing teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching? A. “The PCA will deliver a double dose of medication when you push the button twice.” B. “You can adjust the amount of pain medication you receive by pushing on the keypad.” C. “Continuous PCA infusion is designed to allow fluctuating plasma medication levels.” D. “You should push the button before physical activity to allow maximum pain control.” 83. A nurse is caring for a client who has diabetes mellitus and is receiving long-acting insulin for blood glucose management. The nurse should anticipate administering which of the following types of insulin? A. Glargine insulin. B. Regular insulin. C. NPH insulin. D. Insulin aspart. 84. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following should the toddler participate? A. Looking at alphabet flashcards. B. Playing with a large plastic truck. C. Use scissors cut out paper shapes. D. Watching a cartoon in the dayroom. 85. A nurse is caring for a client who is receiving intermittent feedings via a feeding via a feeding pump and is experiencing dumping syndrome. Which of the following actions should the nurse take? A. Administer a refrigerated feeding. B. Increased the amount of water use to flush the tubing. C. (Unable to read) rate of the client’s feedings. D. Instruct the client to move onto their right side. 86. A nurse in an emergency department is caring for a client who received a dose of penicillin and is now anxious, flushing, tachycardic and has difficulty swallowing. Which of the following actions is the nurse’s priority? A. Monitor the client’s ECG B. Take the client’s vital signs. C. Administer oxygen D. Insert an IV line. 87. A nurse is caring for a client who has Raynaud’s disease. Which of the following actions should the nurse take? A. Provide information about stress management. B. Maintain a cool temperature in the client’s room. C. Administer epinephrine for acute episodes. D. Give glucocorticoid steroid twice per day. 88. A nurse is reviewing the medical history of a client who has angina. Which of the following findings in the client’s medical history should identify as a risk factor for angina? A. Hyperlipidemia. B. COPD C. Seizure disorder D. Hyponatremia. 89. A nurse is caring for a client who is 12 hr. postpartum and has a third- degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer? A. Bisacodyl 10 mg rectal suppository. B. Magnesium hydroxide 30 ml PO. C. Famotidine 20 mg PO. D. Loperamide 4 mg PO. 90. A nurse overhears two assistive personnel (AP) discussing care for a client while in the elevator. Which of the following actions should the nurse take? A. Contact the client’s family about the incident. B. Notify the client’s provider about the incident. C. File a complaint with the facility’s ethics committee. D. Report the incident to the AP’s charge nurse. 91. A nurse is planning care for a client who is receiving hemodialysis. Which of the following actions should the nurse include in the plan of care? A. Withhold all medications until after dialysis B. Rehydrate with dextrose 5% in water for orthostatic hypotension. C. Check the vascular access site for bleeding after dialysis. D. Give an antibiotic 30 min before dialysis. 92. A nurse in the emergency department is caring for a client who reports intimate partner violence. Which of the following interventions is the nurse’s priority? A. Develop a safety plan with the client B. (Unable) options for reporting the incident. C. Refer the client to a community support group. D. Determine if the client has any injuries. 93. A nurse is caring for a client who is in active labor and note the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia? A. Maternal fever B. Fetal anemia C. Maternal hypoglycemia D. Chorioamnionitis 94. A nurse is assessing a school-age child who has a urinary tract infection. Which of the following findings should the nurse expect? A. Periorbital edema. B. Decreased frequency of urination. C. Enuresis. D. Diarrhea. 95. 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 has COPD and a respiratory rate of 44/min B. A client who has cancer with a sealed implant for radiation therapy C. A client who is receiving heparin for deep-vein thrombosis D. A client who is 1 day postoperative following a vertebroplasty 96. A nurse is preparing to administer dopamine hydrochloride 4 mcg/kg/min via continuous infusion. Available is dopamine hydrochloride in a solution of 800 mg in a 250 ml bag. The client weighs 80 kg. The nurses should set the IV infusion to deliver how many mL/hr? (Round the answer to the nearest whole number) 6 mL/hr 97. A nurse is providing teaching to the parents of a newborn genetic screening. Which of the following statement 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. “Your baby will be given 2 ounces of water to drink prior to the test.” D. “This test will be repeated when your baby is 2 months old.” 98. A nurse is providing discharge teaching to a client who is postoperative following a colon resection and has a new ascending colostomy. Which of the following statements by the client indicates an understanding of the teaching? A. “My stool will become fully formed within 3 weeks” B. “My skin will need to be cleaned with alcohol before I apply a new pouch” C. “I should avoid eating popcorn and fresh pineapple” D. “I should expect bruising around the stoma” 99. A nurse is admitting a client who had a stroke and exhibits facial drooping, drooling and hoarseness. Which of the following is the nurse’s priority? A. Refer the client to a speech language pathologist. B. Monitor the client’s prealbumin levels C. Measure the client’s weight. D. Place the client on NPO status. 100. A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make? A. “Taking furosemide can cause your potassium levels to be high” B. “Eat foods that are high in sodium” C. “Rise slowly when getting out of bed” D. “Taking furosemide can cause you to be overhydrated” 101. A nurse is planning a teaching session for a client who is postoperative following a colon resection. Which of the following actions should the nurse take first? A. Providing written material for the client to read B. Plan a short instruction about coughing and deep breathing. C. Determine the client’s current pain level. D. Instruct the client about dietary restrictions. 102. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary recommendations should the nurse make? A. Coffee with creamer. B. Lettuce with sliced avocados. C. Broiled skinless chicken breast with brown rice. D. Warm toast with margarine. 103. A nurse is caring for a client who asks for information regarding organ donation. Which of the following should the nurse make? A. “I cannot be a witness for your consent to donate.” B. “Your name cannot be removed once you are listed on the organ donor list.” C. “Your desire to be an organ donor must be documented in writing.” D. “You must be at least 21 years of age to become an organ donor.” 104. A nurse is teaching a female client about personal hygiene. Which of the client actions indicates an understanding go the teaching? A. The client takes a hot bubble bath every day. B. The client wipes back to front when toileting. C. The client washes her perineum first when bathing. D. The client brushes her teeth twice daily. 107. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take? A. Obtain the newborn’s body temperature using a tympanic thermometer. B. (Unable to read) FACES pain scale. C. Auscultate the newborn’s apical pulse for 60 seconds. D. Measure the newborn’s head circumference over the eyebrows and below the occipital prominence. (NOT) 108. A nurse is caring for a client who has pneumonia and has gained 4.2 kg (9.3 lb) over the last 5 days. The client’s laboratory values this morning are the following: WBC 10,000/mm3, RBC 5.2 million/mm3, platelets 250,000/mm3, BUN, and serum creatinine 2.1 mg/dL. The nurse should report these finding to which of the following members of the interdisciplinary team? A. Dietitian B. Infection control nurse C. Nephrologist D. Cardiologist 109. A nurse is caring for an infant who is in contact isolation and received a blood transfusion. Which of the following actions is appropriate for the nurse to take to provide cost-effective care? A. Return unopened equipment to the supply center B. Leave the unused infusion pump in the room until discharge C. Stock the room with a 2-day supply of disposable diapers D. Being in formula as needed 108. A nurse is reviewing the medical record of a client who is postoperative following a total hip arthroplasty. For which of the following findings should the nurse contact the provider? A. Hear rate 100/min B. Temperature 37.8C (100F) C. Albumin level 4.0 g/dL. D. WBC count 14,000 mm3 109. A nurse is preparing education material for a client. Which of the following techniques should the nurse use in creating material? A. Emphasize important information using bold lettering. B. Use 7th grade reading level. C. Avoid using cartoons in the teaching material. D. Use words with three or four syllables. 110. A nurse is creating for a client who has aids. The client states, “My mouth is sore when I eat.” Which of the following instructions should the nurse provide? A. “Add salt to season” B. “Ice chips” C. “Rinse your mouth with an alcohol-based mouthwash” D. “Eat foods served at hot temperatures” 111. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? A. Vomiting B. Hypertension C. Epigastric pain D. Contractions 112. A nurse is caring for a client who is at 38 weeks gestation, is in active labor, and has ruptured membrane. Which of the following actions should the nurse take? A. Insert an indwelling urinary catheter. B. Apply fetal heart rate monitor. C. Initiate fundal massage. D. Initiate an oxytocin IV infusion. 113. A home health nurse is preparing to make an initial visit to a family following a referral from a local provider. Identify the sequence of steps the nurse should take when conducting a home visit. (Move the steps into the box on the right. Placing them in the order of performance) A. Identify family needs interventions using the nursing process. B. Record information about the home visit according to agency policy. C. Contact the family to determine availability and readiness to make an appointment D. Discuss plans for future visits with the family. E. Clarify the reason for the referral with the provider’s office. E C A B D (My choice) 114. A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for paternal fluid therapy. The guardian asks. “What are the indications that my baby needs an IV?” Which of the following responses should the nurse make? A. “Your baby needs an IV because she is not producing any tears” B. “Your baby needs an IV because her fontanels are budging” C. “Your baby needs an IV because she is breathing slower than normal” D. “Your baby needs an IV because her heart rate is decreasing” 115. A nurse is caring for a client who is receiving intermittent eternal tube feeding. Which of the following places the client at risk for aspiration? A. A residual of 65mL 1 hr postprandial B. A History of gastroesophageal reflux disease C. Sitting in a high-Fowler’s position during the feeding D. Receiving a high osmolarity formula 116. A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching? A. Take magnesium hydroxide for indigestion B. Drink at least 3L of fluid daily C. Eat 1g/kg of protein per day D. Consume foods high in potassium 118. A nurse on a telemetry unit is assessing a client who is receiving continuous cardiac monitoring. The client’s heart rate is 69/min and the PR interval is 0.24 seconds. The nurse should interpret this finding as which of the following cardiac rhythms? A. First degree AV block B. Premature ventricular contraction. C. Sinus bradycardia. D. Atrial fibrillation. 119. A nurse is supervising an assistive personnel (AP) who is feeding a client. The nurse observes that the client coughs after each bite. After asking the AP to stop feeding the client, which of the following actions should the nurse take next? A. Provide the client with an instructional handout about swallowing exercises. B. Ask a speech therapist to evaluate the client’s ability to swallow. C. Discuss the manifestations of impaired swallowing with the AP. D. Listens to the client’s lung sounds. 120. A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan? A. Ask the client directly what he is hearing B. Encourage the client to lie down in a quiet room C. Avoid eye contact with the client D. Refer to the hallucinations as if the are real 120. The nurse is teaching a group of clients at a community health fair about genetic disease. Which of the following statements by a client indicates an understanding of the teaching? A. “If there is a genetic risk for future pregnancies, we can get treatment now to prevent the disease” B. “There is no need to have genetic counseling if I know that I have a family history of mental illness.” C. “My family has genetic risk for breast cancer, so I am considering a total mastectomy” D. “Even if I have a genetic risk for a disease the chance I will get the disease is probably low due to current medical treatments.” 121. A nurse is planning discharge teaching about cord care for the parents of a newborn. Which of the following instructions should the nurse plan to include in the teaching? A. “The cord stump will fall off in 5 days.” B. “Contact the provider if the cord stump turns black.” C. “Clean the base of the cord with hydrogen peroxide daily.” D. “Keep the cord stump dry until it falls off.” 122. A nurse is providing teaching to a client who is on glucocorticoid therapy. Which of the following statements by the client indicates an understanding of the teaching? A. “I have my eyes examines annually” B. “I take a calcium vitamin supplement daily” C. “I limit my intake of foods with potassium” D. “I constantly take my medication between 8 and 9 each evening” 123. A nurse is teaching a newly licensed nurse about ergonomic principles. Which of the following actions by a newly licensed nurse indicates an understanding of the teaching? A. Stands with feet together when lifting a client up in bed. B. Raises the client’s head of bed before pulling the cline up. C. Uses a mechanical lift to move client from bed to chair. D. Places a gait belt around the client’s upper chest before assisting a client to stand. 124. A client is requesting information from a nurse about a nitrazine test. Which of the following statements should the nurse make? A. “Your bladder should be full prior to me performing this test B. “If this test is positive you will be required to have a non-stress test. C. “This test will determine if there is leaking amniotic fluid” D. “I will be taking a blood sample to test for changes in your hormones levels” 125. A Nurse is assessing a client who has hyponatremia and is receiving IV fluid therapy. Which of the following findings indicate the client is developing a complication of therapy? A. Peripheral edema B. Increased thirst. C. Flattened neck veins. D. Hypotension 126. A nurse is conducting a home visit for a family who has two young children. The nurse notes several welts across the backs of the legs of one of the children. Which of the following actions should the nurse take first? A. Document clinical findings. B. Contact child protective services. C. Refer the parents to a self-help group. D. Instruct the parents about methods of discipline. 127. A nurse is planning care for a client who has thrombocytopenia. Which of the following actions should the nurse include? A. Encourage the client to floss daily. B. Remove fresh flowers from the client’s room. C. Provide the client what a stool softener. D. Avoid serving the client raw vegetable. 128. A nurse is assessing a client who is 30 min postoperative following an arterial thrombectomy. Which of the following findings should the nurse to report? A. Chest pain B. Muscle spasms. C. Cool, moist skin. D. Incisional pain. 129. (Unable to read) A. Use NPH insulin to treat ketoacidosis. B. Administer NPH insulin 30 minutes before breakfast. C. (Unable to read) I think this answer was 0.9% sodium chloride D. Discard the NPH insulin vial if the medication is cloudy. 131. A nurse is caring for a client who has left-sided heart failure, and the provider is concerned that the client might develop (Unable to read) Which of the following actions should the nurse take? A. Maintain the client’s oxygen saturation level at 89%. B. Place the client’s lower extremities on two pillows. C. Recommended that the client follow a 3g sodium diet. D. Place the client in high fowler’s position. 132. A charge nurse is teaching a newly licensed nurse about the administration of total parenteral nutrition. Which of the following should the charge nurse include? A. “You will need to monitor the client’s electrolytes daily” B. “You will need to change the IV dressing site once per week” C. “You will need to warm the solution in the microwave before administration” D. “You need to weigh the client twice per week” 133. A nurse is teaching a prenatal class about infection 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 take antibiotics when I have a virus.” D. “I should wash my hands for 10 seconds with hot after working in the garden.” 133. A nurse is caring for a client who has end-stage liver cancer. Which of the following statements should the nurse make to support the client’s right to autonomy? A. “You should trust that your care team has your best interest at heart” B. “I will not share any personal information without your permission C. “The health care team will do their best to keep any promise we make to you” D. “We encourage you to participate in all decisions about your treatment” 134. A nurse is completing an incident report after a client fall. Which of the following competencies of Quality and Safety Education for Nurse is the use demonstrating? A. Quality improvement. B. Patient (Unable to read) C. Evidence based practice. D. Informatics. 136. A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of the following actions should the nurse take? A. Confront the nurse about the suspected alcohol use. B. Inform another nurse on the unit about the suspected alcohol use. C. Ask the nurse to finish administering medications and then go home. D. Notify the nursing manager about the suspected alcohol use. 137. A charge nurse is teaching new staff members about factors that increase a client’s risk to become violet. Which of the following risk factors should the nurse include as the best predictor of future violence? A. Previous violent behavior B. A history of being in prison C. Experiencing delusions D. Male gender 137. A charge nurse is teaching a newly licensed nurse about medication administration. Which of the following information should the charge nurse include? A. Inform clients about the action of each medication prior to administration. B. (Unable to read) two times prior to administration. C. Complete an incident report if a client vomits after taking a medication. D. Avoid preparing medications for more than two clients at one time. 138. A charge nurse is evaluating the time management skills of a newly licensed nurse. For which of the following actions by the newly licensed nurse should the charge nurse intervene? A. Takes assigned breaks at regular intervals B. Documents the clients care tasks at the end of the shift. C. assisting with ADLs to perform time sensitive activities D. Gather necessary supplies before beginning a dressing change. 139. A nurse is caring for a client who has diaper dermatitis. Which of the following actions should the nurse take? A. Apply zinc oxide ointment to the irritated area. B. (Unable to read) C. Wipe stool from the skin using store bought baby wipes. D. Apply talcum powder to the irritated area. 140. A nurse is assessing a client who had an uncomplicated vaginal birth 3 days ago. In which of the following locations should the nurse expect to palpate the client’s fundus? C 142. A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? A. “The client might act seductively.” B. “The client is overly concentrated about minor details.” C. “The client exhibits impulsive behaviors.” D. “The client is exceptionally clingy to others.” 142. A nurse is caring for a client who has a prescription for warfarin. When reviewing the client’s current medications, which of the following medications should the nurse identify as contraindicated for use with warfarin? (Select all that apply) A. Aspirin B. Magnesium sulfate C. Gingko biloba. D. Cetirizine E. Ibuprofen. 143. A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect? A. Ritual behavior B. Suspicious of others C. Exhibits separation anxiety D. Preoccupied with aging 144. A nurse is calculating the body mass index (BMI) of a client who weighs 75 kg (165.3 lb) and is 1.8 m (5 ft 9 in) tall. The nurse should calculate the client’s BMI value as which of the following? A. 23 B. 42 C. 32 D. 8 145. A nurses is assessing a preschooler who has recently experienced an unexpected death in the family. Which of the following should the nurse recognize as an expected finding? A. The child expresses curiosity about the death process. B. The child refuses to talk about death. C. The child believes the person will return. D. The child focuses on his own mortality. 146. A nurse is assessing a client in the emergency department. Which of the following actions should the nurse take first? Exhibit 1 Laboratory Results Cerebrospinal fluid WBC 2,000/mm3 Neutrophils 88% Protein 320 mg/dl Glucose 35 mg/dl Cloudy in appearance Exhibit 2 History and Physical Reports severe headache and photophobia. Disoriented to person, place, and time. Lethargic. Exhibit 3 Vital Signs BP 166/96 mm Hg Respiratory rate 24/min Pulse rate 112/min Temperature 39.3C (102.8F) Pain of 6 on a scale from 0 to 10 Glasgow score 9 A. Place the client on a cooling blanket. B. Administer an analgesic. C. Obtain arterial blood gas levels. D. Elevate the head of the client’s bed 30 degrees. 147. A client is caring for a client following a paracentesis. Which of the following findings should the nurse identify as an indication of a complication? A. Decreased hematocrit. B. Increased blood pressure. C. Tachycardia. D. Hypothermia. 148. A certified IV nurse is providing education about peripherally inserted catheters (PICC) to a newly licensed nurse. Which of the following statements by the newly licensed nurse indicated an understanding of the teaching? A. “Use a vein in the middle of the lower arm to insert a PICC.” B. “Flush a PICC using a 3-milliliter syringe.” C. “Informed consent is required prior to PICC placement.” D. “Position the client’s arm in adduction for PICC placement.” 149. A nurse is reviewing admission prescriptions for a group of clients. Which of the following prescriptions should the nurse identify as complete? A. Furosemide 20 mg BID B. Nitroglycerin transdermal patch. C. Aspirin 1 tablet daily. D. Metoprolol 5mg IV now. 150. A nurse is caring a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? A. Hold hand flat to perform percussion on the child B. Perform the procedure twice a day C. Administer a bronchodilator after the procedure D. Perform the procedure prior to meals 151. A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings requires follow up care? A. A client who received a Mantoux test 48hr ago and has an induration B. A client who is schedule for a colonoscopy and is taking sodium phosphate C. A client who is taking warfarin and has an INR of 1.8 D. A client who is takin bumetanide and has a potassium level of 3.6 mEq/L 152. A nurse is caring for a client who is postpartum and request information about contraception. Which of the following instructions should the nurse include? A. “The lactation amenorrhea method is effective for your first year postpartum” B. “You can continue to use the diaphragm used before your pregnancy” C. “Place transdermal birth control patch on your upper arm” D. “I should avoid vaginal spermicides while breast feeding.” 153. A nurse is reviewing the facility’s safety protocols considering newborn abduction with the parent of a newborn. Which of the following statements indicates an understanding of the teaching? A. “Staff will apply identification band after first bath” B. “I will not publish public announcement about my baby’s birth” C. “I can remove my baby’s identification band as long as she is in my room” D. “I can leave my baby in my room while I walk in the hallway” 154. 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. Give the protamine if signs of magnesium sulfate toxicity occur C. Monitor the FHR via Doppler every 30min D. Measure the client’s urine output every hour 155. A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record? A. “Morphine 3 mg SQ every 4 hr. PRN for pain.” B. “Morphine 3 mg Subcutaneous (Unable to read) C. “Morphine 3.0 mg sub q every 4 hr. PRN for pain.” D. “Morphine 3 mg SC q 4 hr. PRN for pain.” 156. A nurse is assessing a client who has acute kidney injury and a respiratory rate of 34/min. The client’s ABG results are ph. 7.28 HCO3 18 mEq/L. (Unable to read) PaO2 90 mm Hg. Which of the following conditions should the nurse expect? A. Metabolic acidosis. B. Metabolic alkalosis. C. Respiratory acidosis. D. Respiratory alkalosis. 157. A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first? A. Notify the provider. B. Report the incident to the nurse manager. C. Monitor vital signs. D. Fill out an incident report. 158. recieves a telephone call from a parent reporting that their school-age child has a nosebleed and that they cannot stop the bleeding. Which of the following instructions should the nurse provide to the provider? A. “Have your child lie down and turn their head to their side for 10 minutes” B. “Use your thumb and forefinger to apply pressure to the (Unable to read) of your child’s nose” C. “Place a warm wet washcloth over your child’s forehead and the bridge of their nose” D. “Tell your child to blow their nose gently and then sit down and tilt your head back” 159. A nurse is preparing to administer an autologous blood product to a client. Which of the following actions should the nurse take to identify the client? A. Match the client’s blood type with the type and cross match specimens. B. Confirm the provider’s prescription matches the number on the blood component. C. Ask the client to state the blood type and the date of their last blood donation. D. Ensure that the client’s identification band matches the number on the blood unit. 160. A nurse is transcribing new medication prescriptions for a group of client. For which of the following prescriptions should the nurse contact the provider for clarifications? A. Zolpidem 10mg PO one tablet at bedtime B. Hydrochlorothiazide 12.5 mg PO BID C. Triamcinolone acetonide 100 mcg/inhalation two puffs TID D. Lorazepam .5mg PO one tablet daily 161. A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take? A. Offer fluids every 2hr. B. Document the client’s behavior prior to being placed in seclusion. C. Discuss with the client his inappropriate behavior prior to seclusion. D. Assess the client’s behavior once every hour. 162. A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make? A. “Dehydration is treated with calcium supplements” B. “Dehydration can increase the risk of preterm labor” C. “Dehydration associated gastroesophageal reflux D. “Dehydration is caused by a decreased hemoglobin and hematocrit” 163. A nurse is using an IV pump for a newly admitted client. Which of the following actions should the nurse take? A. (Unable to read) B. (Unable to read) C. Grasp the IV pump cord when unplugging it from the electrical outlet. D. (Unable to read) outlet has two prongs for the IV pump. 164. A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 ml/hr. Which of the following interventions should the nurse anticipate? A. Clamp the (Unable to read) B. Administer fluid bolus. C. Obtain a urine specimen for culture and sensitivity D. Initiate continuous bladder irrigation. 165. A nurse is reviewing the medical record of a client who has 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 166. A nurse is receiving a change-of-shift report for an adult female client who is postoperative. Which of the following client information should the nurse report? A. (Unable to read) B. (Unable to read) C. Answer might be lower platelets. D. (Unable to read) 167. A nurse is caring for a client who has depression and reports taking ST. John’s wort along with citalopram. The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances? A. Serotonin syndrome B. Tardive dyskinesia C. Pseudo parkinsonism. D. Acute dystonia. 168. A client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse nutritional requirements? A. (Unable to read) (Chose this one) B. Keep a calorie count for food and beverages. C. Schedule meals at 6 hr. intervals D. Provide low-protein high carbohydrate diet 169. D 170. A nurse in a provider’s office is preparing to administer the inactivated influenza vaccine. The nurse should collect additional (Unable to read) for which of the following client prior to administering the vaccine? A. (Unable to read B. Client has (Unable to read) HIV/AIDS C. Client has a sensitivity to eggs. D. Client is experiencing seasonal allergies. 171. A nurse is providing teaching about digoxin administration to the parents of a toddler which as heart failure. Which of the following statements should the nurse include in the teaching? A. “Limit your child’s potassium intake while she is taking this medication.” B. “You can add the medication to a half-cup of your child’s favorite juice.” C. “Repeat the does if your child vomits within 1 hour after taking the medication.” D. “Have your child drink a small glass of water after swallowing the medication.” 171. A nurse is teaching about preventing sudden infant syndrome (SIDS) to parent of a 1-month-old infant. Which of the following indicates that the parent understands how to place the infant in the crib at bed time? B 172. A nurse is collecting a sputum specimen from a client who has tuberculosis. Which of the following actions should the nurse take? A. Obtain the specimen immediately upon the client waking up. B. Wait 1 day to collect the specimen if the client cannot provide sputum. C. Ask the client to provide 15 to 20 ml of sputum in the container. D. Wear sterile gloves to collect specimen from the client. A. nurse is reviewing the laboratory report of a client who has a prescription for digoxin. For which of the following laboratory results should the nurse withhold the medication and notify the provider? A. Digoxin 0.8 ng/ml B. Sodium (Was out of range) C. BUN 15 D. Potassium 3.1 mEq/L. 174. A nurse is caring for a client who wears glasses. Which of the following actions should the nurse take? A. Store the glasses in a labeled case. B. Clean the glasses with hot water. C. Clean the glasses with a paper towel. D. Store the glasses on the bedside table. 175. A school nurse is teaching a parent about absent seizures. Which of the following information should the nurse include? A. “This type of seizure can be mistaken for daydreaming.” B. “This type of seizure lasts 30 to 60 seconds.” C. “The child usually has an aura prior to onset.” D. “This type of seizure has a gradual onset.” 176. A nurse is planning care for a client who has cancer and is about to receive low dose brachytherapy via a vaginal implant applicator. Which of the following interventions should the nurse include in the plan of care? A. Removal of vaginal packing B. Insertion of an indwelling urinary catheter C. Ambulation four times daily D. Maintenance of NPO status until therapy is complete 177. A nurse is caring for a client who has deep vein thrombosis and is receiving heparin therapy. Which of the following tests should the nurse use to monitor and regulate the dosage of the medications? A. aPTT. B. Pyro (Unsure if that’s the writing) C. Platelet count. D. INR. 178. A charge nurse is preparing to lead negotiations among nursing staff due to conflict about overtime requirements. Which of the following strategies should the nurse use to promote effective negotiation? A. Identify solutions prior to negotiation B. Focus on how the conflict occurred C. Attempts to understand both sides of the issue D. Personalize the conflict 179. A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. Which of the following instructions should the nurse include? A. Use the client’s children to provide interpretation. B. (Answer was the nurse was going to do the interpretation) C. Offer client’s translation services for a nominal fee. D. Evaluate the clients’ understanding at regular intervals. 180. A nurse is caring for a client who experienced a traumatic brain injury 72 hr. ago. Which of the following findings should the nurse identify as an indication of intercranial pressure? A. Tachycardia. B. Narrowed pulse pressure. C. Hypotension. D. Increasingly severe headache. RN Comprehensive Predictor 2019 Form B 1. A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl. Which of the following manifestations should the nurse expect? A. Loose stools B. Jitteriness C. Hypertonia D. Abdominal distention 2. A nurse is assessing a client who is immediately post-operative following hip arthroplasty, which of the following considerations should the nurse take when positioning the client? A. Place the client’s heels directly against the bed mattress B. Ensure that the client’s hips remain in an abducted position. C. Maintain the client in a supine position for the first 24 hr. after surgery. D. Flex the client’s hip up to 120° when sitting in a chair. 3. A nurse is assessing a client who is immediately postoperative following a subtotal thyroidectomy. Which of the following should the nurse expect to administer? A. Calcium gluconate. B. Sodium bicarbonate. C. Potassium chloride. D. Sodium phosphate. 4. A nurse is caring for an adult client who has prescriptions for multiple medications. Which of the following (Unable to read) as an age-related change that increases the risk for adverse effects from this medication? A. Rapid gastric emptying. B. Prolonged medication half-life. C. Increased medication elimination. D. Decreased medication sensitivity. 5. A nurse manager is planning to promote client advocacy among staff in a medical unit. Which of the following actions should the nurse take? A. Encourage staff to implement the principle of paternalism when a client is having difficulty making a choice. B. Tell staff explain procedures to clients before obtaining informed consent. C. Instruct unit staff to share personal experiences to help clients make decisions. D. Develop a system for staff members to report safety concerns in the client care environment. 6. C 7. A nurse is providing teaching about the gastrostomy tube feedings to the parents of a school age child. Which of the following instructions should the nurse take? A. Administer the feeding over 30 min. B. Place the child in as supine position after the feeding. C. Charge the feeding bag and tubing every 3 days. D. Warm the formula in the microwave prior to administration. 8. A nurse is administering digoxin 0.125 mg Po to an adult client. For which of the following findings should the nurse report to the provider? A. Potassium level 4.2 mEq/L. B. Apical pulse 58/min. C. Digoxin level 1 ng/ml. D. Constipation for 2 days. 9. A 10.A nurse is caring for an adolescent who has sickle-cell anemia. Which of the following manifestations indicates acute chest syndrome and should be immediately reported to the provider? A. Substernal retractions. B. Hematuria. C. Temperature 37.9 C (100.2 F). D. Sneezing. 11. C 12. A nurse is preforming a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following action should the nurse take? A. Instill 500 ml of solution through the NG tube. B. Insert a large-bore NG tube. C. Use a cold irrigation solution. D. Instruct the client to lie on his right side. 13. A nurse is providing care for a client who is in the advance stage of amyotrophic lateral sclerosis. (ALS). Which of the following referrals is the nurse’s priority? A. Psychologist. B. Social worker. C. Occupational therapist. D. Speech-language pathologist. 14.A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which of the following findings should the nurse report to the provider? A. WBC count 8,000/mm3. B. Platelets 150,000/mm3. C. Aspartate aminotransferase 10 units/L. D. Erythrocyte sedimentation rate 75 mm/hr 15. A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests? A. Platelet count. B. Potassium level. C. Creatine clearance. D. Prealbumin. 16. D 17. A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client’s family want the client to have life- sustaining measures. Which of the following action should the nurse take? A. Arrange for an ethics committee meeting to address the family’s concerns. B. Support the family’s decision and initiate life-sustaining measures. C. Complete an incident report. D. Encourage the family to contact an attorney. 18. A nurse is caring for a client who wears glasses. Which of the following actions should the nurse take? A. Store the glasses in a labeled case. B. Clean the glasses with hot water. C. Clean the glasses with a paper towel. D. Store the glasses on the bedside table. 19. A nurse is teaching a group of newly licensed nurses about measures to take when caring for a client who is on contact precautions. Which of the following should the nurse include in the teaching? A. Remove the protective gown after the client’s room. B. Place the client in a room with negative pressure. C. Wear gloves when providing care to the client. D. Wear a mask when changing the linens in the client’s room. 20.A nurse is planning on care for a client who is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following instructions should the nurse include? A. Perform an ECG every 12 hr. B. Place the client in a supine position while resting. C. Draw a troponin level every 4hr. D. Obtain a cardiac rehabilitation consultation. 21. The nurse is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client’s history is a contradiction to the use of oral contraceptives? A. Hyperthyroidism. B. Thrombophlebitis. C. Diverticulosis. D. Hypocalcemia. 22. A nurse is caring for a client who request the creation of a living will. Which of the following actions should the nurse take? A. Schedule a meeting between the hospital ethics committee and the client. B. Evaluate the client’s understanding of life-sustaining measures. C. Determine the client’s preferences about post mortem care. D. Request a conference with the client’s family. 23. C 24. A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first? A. Place an ice pack over the cast. B. Palpate the pulse distal to the cast. C. Teach the client to keep the cast clean and dry. D. Position the casted extremity on a pillow. 25. A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply) A. Keep objects in the client’s room in the same place. B. Ensure there is high-wattage lighting in the client’s room. C. Approach the client from the side. D. Allow extra time for the client to perform tasks. E. Touch the client gently to announce presence. 26. A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions about the disease. To research the nurse should identify that which of the following electronic database has the most comprehensive collection of nursing (Unable to read) articles? A. MEDLINE B. CINAHL. C. ProQuest. D. Health Source. 27. A nurse in an emergency department is assessing newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following should actions should the nurse take first? A. Obtain a baseline ECG. B. Obtain a blood specimen for ABG analysis. C. Insert an 18-gauge IV catheter. D. Administer 100% humidified oxygen. 28. A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan? A. Place food on the left side of the client’s mouth when he is ready to eat. B. Provide total care in performing the client’s ADLs. C. Maintain the client on bed rest. D. Place the client’s left arm on a pillow while he is sitting. 29. A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take? A. Confront the client about this behavior. B. Express sympathy for the client’s situation. C. Speak assertively to the client. D. Stand within 30 cm (1 ft) of the client when speaking with them. 30. A nurse is caring for a client who is receiving brachytherapy for treatment of prostate cancer. Which of the following actions should the nurse take? A. Cleanse equipment before removal from the client’s room. B. Limit the client’s visitors to 30 min per day. C. Discard the client’s linens in a double bag. D. Discard the radioactive source in a biohazard bag. 31. A 32. A nurse is caring for a client who is in labor and requires augmentation of labor. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin. A. Diabetes mellitus. B. Shoulder presentation. C. Postterm with oligohydramnios. (I think Maternal Newborn Chapter 15 page 100) D. Chorioamnionitis. 33. B 34. A nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse identify as a manifestation of pulmonary congestion? A. Frothy, pink sputum. B. Jugular vein distention. C. Weight gain. D. Bradypnea. 35. A 36. A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for paternal fluid therapy. The guardian asks. “What are the indications that my baby needs an IV?” Which of the following responses should the nurse make? A. “Your baby needs an IV because she is not producing any tears” B. “Your baby needs an IV because her fontanels are budging” C. “Your baby needs an IV because she is breathing slower than normal” D. “Your baby needs an IV because her heart rate is decreasing” 37. A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make? A. “Taking furosemide can cause your potassium levels to be high” B. “Eat foods that are high in sodium” C. “Rise slowly when getting out of bed” D. “Taking furosemide can cause you to be overhydrated” 38. A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse take? A. Allow the client enough time to perform rituals. B. Give the client autonomy in scheduling activities. C. Discourage the client from exploring irrational fears. D. Provide negative reinforcement for ritualistic behaviors. 39. A nurse is caring for a client who has depression and reports taking ST. John’s wort along with citalopram. The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances? A. Serotonin syndrome B. Tardive dyskinesia C. Pseudo parkinsonism. D. Acute dystonia. 40. A nurse is assessing a client who is receiving packed RBCs. Which of the following findings indicate fluid overload? A. Low back pain. B. Dyspnea. C. Hypotension. D. Thready pulse. 41. A nurse is calculating a client’s expected date of delivery. The client’s last menstrual period began on April 12. Using Nagele’s rule, what date should the nurse determine to be the client’s expected delivery date? (Use mmdd format.) 0119 date 42. A nurse is discussing group treatment and therapy with a client. The nurse should include which of the following as being a characteristic of a therapeutic group? A. The group is organized in an autocratic structure. B. The group encourages members to focus on a particular issue. (Mental Health Chapter 8 Page 42) C. The group must be led by a licensed psychiatrist. D. The group encourages clients to form dependent relationships. 43. A nurse manger is reviewing documentation with a newly licensed nurse. Which of the following notations by the newly licensed nurse indicates an understanding of the teaching. UNSURE IF ON THE REPORT A. “OOB with assistance for breakfast” B. “Given 2 mg MSO4 IM for report of pain” C. “Dressing changed qd” D. “Administered 8 u regular insulin sq.” 44. A nurse is preparing to administer eye drops to a school-age child. Identify the actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 1. Apply pressure to the lacrimal punctum. 2. Ask the child to look upward. 3. Pull the lower eyelid downward. 4. Instill the drops of medication. 5. Place the child in a sitting position. 5 2 3 4 1 45. A nurse is caring for a client who speaks a language different from the nurse. Which of the following should the nurse take? A. Request an interpreter of a different sex from the client. B. Request a family member or friend to interpret information for the client. C. Direct attention toward the interpreter when speaking to the client. D. Review the facility policy about the use of an interpreter. 46. A nurse is caring for a client who is in labor and is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion? ON THE REPORT needs double checking A. Urine output 20 ml/hr. B. Montevideo units constantly 300 mm Hg. C. FHR pattern with absent variability. D. Contractions every 5 min that last 30 seconds. 47. C 48. A public health nurse is managing several projects for the community. Which of the following interventions should the nurse identify as a primary prevention strategy? A. Teaching parenting skills to expectant mothers and their partners. B. Conducting mental health screenings at the local community center. C. Referring client who have obesity to community exercise programs. D. Providing crisis intervention through a mobile counseling unit. 49. D 50. C 51. D 52. A nurse is preparing to administer an autologous blood product to a client. Which of the following actions should the nurse take to identify the client? A. Match the client’s blood type with the type and cross match specimens. B. Confirm the provider’s prescription matches the number on the blood component. C. Ask the client to state the blood type and the date of their last blood donation. D. Ensure that the client’s identification band matches the number on the blood unit. 53. A nurse is performing physical therapy for a client who has Parkinson’s disease. Which of the following statements by the client indicates the need for a referral to physical therapy? A. “I have been experiencing more tremors in my left arm than before” B. “I noticed that I am having a harder time holding on to my toothbrush” C. “Lately, I feel like my feet are freezing up, as they are stuck to the ground” D. “Sometimes, I feel I am making a chewing motion when I’m not eating” 54. A nurse is reviewing laboratory data for a client who has chronic kidney disease. Which of the following findings should the nurse expect? A. Increased creatine. B. Increased hemoglobin. C. Increased bicarbonate. D. Increased calcium. 55. A nurse is administering a scheduled medication to a client. The client reports that the medication appears different than what they take at home. Which of the following responses should the nurse take? A. “Did the doctor discuss with you that there was a change in this medication?” B. “I recommend that you take this medication as prescribed” C. “Do you know why this medication is being prescribed to you?” D. “I will call the pharmacist now to check on this medication” 56. A nurse is teaching at a community health fair about electrical fire prevention. Which of the following information should the nurse include in the teaching? A. Use three pronged grounded plugs. B. Cover extension cords with a rug. C. Check the tingling sensations around the cord to ensure the electricity is working. D. Remove the plug from the socket by pulling the cord. 57. A charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge? A. A 42-year-old client who has preeclampsia and a BP of 166/110 mm Hg. B. A 15-year-old client who delivered via emergency cesarean birth 1 day ago. C. A client who received 2 units of packed RBCs 6 hr. ago for a postpartum hemorrhage. D. A client who delivered precipitously 36 hr. ago and has a second-degree perineal laceration. 58. A nurse in a provider’s office is reviewing the laboratory results of a group of clients. Which to report? A. Herpes simplex. B. Human papillomavirus C. Candidiasis D. Chlamydia 59. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian A. A client who has a prescription for warfarin and states “I will need to limit how much spinach I eat”. B. A client who has gout and states, “I can continue to eat anchovies on my pizza.” C. A client who has a prescription for spironolactone and states “I will reduce my intake of foods that contain potassium”. D. A client who has (Unable to read) and states “I’ll plan to take my calcium carbonate with a full glass of water”. 60. 40. A nurse is preparing to measure a temperature of an infant. Which of the following action should the nurse take? A. Place the tip of the thermometer under the center of the infant’s axilla. B. Pull the pinna of the infant’s ear forward before inserting the probe. C. Insert the probe 3.8 cm (1.5in) into the infant’s rectum. D. Insert the thermometer in front of the infant’s tongue. 61. A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella rooster. Which of the following information should the nurse include? A. Children who have varicella are contagious until vesicles are crusted. B. Children who have varicella should receive the herpes zoster vaccination. C. Children who have varicella should be placed in droplet precaution. D. Children who have varicella are contagious 4 days before the first vesicle eruption. 62.A nurse is reviewing the laboratory report of a client who has been having lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect? A. Withhold the next dose. B. Increase the dosage. C. Discontinue the medication. D. Administer the medication. 63. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer? A. Pregabalin B. Lorazepam C. Colchicine D. Codeine. 64. A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take? A. Prime IV tubing with 0.9% sodium chloride. B. Use a 24-gauge IV catheter C. Obtain filter less IV tubing. D. Place blood in the warmer for 1 hr. 65. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following should the toddler participate? A. Looking at alphabet flashcards. B. Playing with a large plastic truck. C. Use scissors cut out paper shapes. D. Watching a cartoon in the dayroom. 66. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary recommendations should the nurse make? A. Coffee with creamer. B. Lettuce with sliced avocados. C. Broiled skinless chicken breast with brown rice. D. Warm toast with margarine. 67. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take? A. Obtain the newborn’s body temperature using a tympanic thermometer. B. (Unable to read) FACES pain scale. C. Auscultate the newborn’s apical pulse for 60 seconds. D. Measure the newborn’s head circumference over the eyebrows and below the occipital prominence. (NOT) 68. A nurse is caring for a client who is at 38 weeks gestation, is in active labor, and has ruptured membrane. Which of the following actions should the nurse take? A. Insert an indwelling urinary catheter. B. Apply fetal heart rate monitor. C. Initiate fundal massage. D. Initiate an oxytocin IV infusion. 69. A nurse is assessing a client who is 30 min postoperative following an arterial thrombectomy. Which of the following findings should the nurse to report? A. Chest pain B. Muscle spasms. C. Cool, moist skin. D. Incisional pain. 70. A nurse is completing an incident report after a client fall. Which of the following competencies of Quality and Safety Education for Nurse is the use demonstrating? A. Quality improvement. B. Patient (Unable to read) C. Evidence based practice. D. Informatics. 71. A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of the following actions should the nurse take? A. Confront the nurse about the suspected alcohol use. B. Inform another nurse on the unit about the suspected alcohol use. C. Ask the nurse to finish administering medications and then go home. D. Notify the nursing manager about the suspected alcohol use. 72. A nurse is caring for a client who has diaper dermatitis. Which of the following actions should the nurse take? A. Apply zinc oxide ointment to the irritated area. B. (Unable to read) C. Wipe stool from the skin using store bought baby wipes. D. Apply talcum powder to the irritated area. 73. A nurse is reviewing the facility’s safety protocols considering newborn abduction with the parent of a newborn. Which of the following statements indicates an understanding of the teaching? A. “Staff will apply identification band after first bath” B. “I will not publish public announcement about my baby’s birth” C. “I can remove my baby’s identification band as long as she is in my room” D. “I can leave my baby in my room while I walk in the hallway” 74. A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record? A. “Morphine 3 mg SQ every 4 hr. PRN for pain.” B. “Morphine 3 mg Subcutaneous (Unable to read) C. “Morphine 3.0 mg sub q every 4 hr. PRN for pain.” D. “Morphine 3 mg SC q 4 hr. PRN for pain.” 75. A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first? A. Notify the provider. B. Report the incident to the nurse manager. C. Monitor vital signs. D. Fill out an incident report. 76. A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make? A. “Dehydration is treated with calcium supplements” B. “Dehydration can increase the risk of preterm labor” C. “Dehydration associated gastroesophageal reflux” D. “Dehydration is caused by a decreased hemoglobin and hematocrit” 77. A nurse is receiving a change-of-shift report for an adult female client who is postoperative. Which of the following client information should the nurse report? A. (Unable to read) B. (Unable to read) C. Answer might be lower platelets. D. (Unable to read) 78. A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. Which of the following instructions should the nurse include? A. Use the client’s children to provide interpretation. B. (Answer was the nurse was going to do the interpretation) C. Offer client’s translation services for a nominal fee. D. Evaluate the clients’ understanding at regular intervals. areas A. Buttocks. B. Upper back. C. Hamstring area. 133. Bariatric Surgery • Instruct the client on limitations regarding liquids or pureed foods for the first 6 weeks, as well as the volume that can be consumed (often not to exceed 1 cup). • Instruct the client to walk daily for at least 30 min. • Remind the client that overeating can dilate the surgically created pouch causing weight to be regained. • Instruct the client to take vitamin and mineral supplements. Cancer Treatment Options: Adverse Effects of Radiation Therapy (Active Learning Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 91) • Adverse effects on tissues within the radiation path include • Skin changes • Hair loss • Debilitating fatigue Cancer and Immunosuppression Disorders: Teaching a Client Who Is Undergoing Radiation Therapy (RN QSEN - Patient-centered Care, Active Learning Template - Basic Concept, RM Nutrition 6.0 Chp. 16) • Nausea, vomiting o Eat cold or room-temperature foods. o Try high-carbohydrate, low-fat foods. o Avoid fried foods. o Do not eat prior to chemotherapy or radiation. o Take prescribed antiemetic medication. o Sit up for 1 hr after a meal. Nursing Care of Newborns: Preventing Heat Loss Through Conduction (RN QSEN - Safety, Active Learning Template - Basic Concept, RM MN RN 10.0 Chp 24) • Conduction: Loss of body heat resulting from direct contact with a cooler surface. o Preheat a radiant warmer, warm a stethoscope and other instruments, and pad a scale before weighing the newborn. The newborn should be placed directly on the mother’s chest and covered with a warm blanket. Nonopioid Analgesics: Pain Medication for a Client Who Has Cholelithiasis (Active Learning Template - System Disorder, RM Pharm RN 7.0 Chp 35) • Lanreotide Medications Affecting Coagulation: Medication Interactions with Warfarin (RN QSEN - Safety, Active Learning Template - Medication, RM Pharm RN 7.0 Chp 25) • Concurrent use of these medications increases the risk for bleeding o Heparin o Aspirin o Acetaminophen o Glucocorticoids o Sulfonamides o Parenteral cephalosporins Prenatal Care: Teaching About Intercourse During Pregnancy (RN QSEN - Patient- centered Care, Active Learning Template - Basic Concept, RM MN RN 10.0 Chp 4) • The client should urinate before and after intercourse to flush bacteria from the urethra that are present or introduced during intercourse ATI COMPREHENSIVE C 1. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following should the actions the nurse take? A. Request a renewal of the prescription every 8 hr. B. Check the client’s peripheral pulse rate every 30 min C. Obtain a prescription for restraint within 4 hr. D. Document the client’s condition every 15 minutes 2. A nursing planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care? a. Offer small amounts of clear liquids 6 hr following surgery (assess for gag reflex first) b. Give cromolyn nebulizer solution every 6 hr (for asthma) c. Apply a warm compress to the operative site every 4 hr d. Administer analgesics on a scheduled basis for the first 24 hr 3. 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. A client who has sinus arrhythmia and is receiving cardiac monitoring b. A client who has diabetes mellitus and a hemoglobin A1C of 6.8% c. A client who has epidural analgesia and weakness in the lower extremities d. A client who has a hip fracture and a new onset of tachypnea 4. A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse tak e? a. Shave hairy areas of skin prior to application (apply to hairless, clean & dry areas to promote absorption; avoid oily or broken skin) b. Wear gloves to apply the patch to the client’s skin c. Apply the patch within 1 hr of removing it from the protective pouch (apply immediately) d. Remove the previous patch and place it in a tissue (fold patch in half with sticky sides pressed together) 5. A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first? a. A client who was just given a glass of orange juice for a low blood glucose level b. A client who is schedule for a procedure in 1 hr (can wait) c. A client who has 100 mL fluid remaining in his IV bag (can wait) d. A client who received a pain medication 30 min ago for postoperative pain 6. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration? a. A history of gastroesophageal reflux disease b. Receiving a high osmolarity formula c. Sitting in a high-Fowler’s position during the feeding d. A residual of 65 mL 1hr postprandial 7. A nurse is reviewing the laboratory results for a client who has Cushing’s disease. The nurse should expect the client to have an increase in which of the following laboratory values? a. Serum glucose level- increased b. Serum calcium level-decreased c. Lymphocyte count- decreased immune system. d. Serum potassium level- decreased . 8. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displaces toxicity. Which of the following actions should the nurse take? a. Position the client supine b. Prepare an IV bolus of dextrose 5% in water c. Administer methylergonovine IM d. Administer calcium gluconate IV Calcium gluconate is given for magnesium sulfate toxicity. Always have an injectable form of calcium gluconate available when administering magnesium sulfate by IV. 9. A charge nurse is teaching new staff members about factors that increase a client’s risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence? a. Experiencing delusions b. Male gender c. Previous violent behavior d. A history of being in prison Risk factors also include: past history of aggression, poor impulse control, and violence. Comorbidity that leads to acts of violence (psychotic delusions, command hallucinations, violent angry reactions with cognitive disorders). Individual Assessment for Violence 10. A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field? a. Place the cap from the solution sterile side up on clean surface b. Open the outermost flap of the sterile kit toward the body→ flap AWAY from the body's first c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field → 2.5 cm (1-inch) border around any sterile drape or wrap that is considered contaminated. d. Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW waist level; should be ABOVE waist level 11. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? a. Eat a light snack before bedtime b. Stay in bed at least 1 hr if unable to fall asleep c. Take a 1 hr nap during the day d. Perform exercises prior to bedtime 12. A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following actions should the nurse take first? a. Educate the client about current medical diagnosis b. Refer the client to a meal delivery program c. Identify environmental hazards in the home d. Arrange for client transportation to follow-up appointments Rationale Priority: Assess first. 13. A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following questions should the nurse ask the client? a. “Can you tell me who visited you today?” b. “What high school did you graduate from c. “Can you list your current medications?” d. “What did you have for breakfast yesterday?” 14. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching a. HbA1c level greater than 8%- 6.5 - 8 is the target reference. > b. Blood glucose level greater than 200 mg/dL at bedtime c. Blood glucose level less than 60 mg/dL before breakfast- < 70 = HYPOGLYCEMIC d. HbA1c level less than 7% 15. A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination? a. The client is experiencing an adverse reaction to rifampin b. The client’s seizure disorder is no longer under control c. The client is showing evidence of phenytoin toxicity d. The client is having adverse effects due to combination antimicrobial therapy 16. A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse? a. Increase in frequency of swallowing→ may indicate bleeding b. Moderate sanguineous drainage on the drip pad c. Bruising to the face→ side effect d. Absent gag reflex→ possibly due to anesthesia given. (1 hour postoperative) Rationale “Requires immediate action” choose the worst possibility that could lead to. ABC 17. A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease. Which of the following interventions should the nurse include in the plan of care? a. Give scheduled doses of acetaminophen every 6 hr b. Monitor the child’s cardiac status c. Administer antibiotics via intermittent IV bolus for 24 hr d. Provide stimulation with children of the same age in the playroom 18. A nurse is planning an educational program for high school students about cigarette smoking. Which of the following potential consequences of smoking is most likely to discourage adolescents from using tobacco? a. Use of tobacco might lead to alcohol and drug abuse b. Smoking in adolescence increases the risk of developing lung cancer later in life c. Use of tobacco decreases the level of athletic ability d. Smoking in adolescence increases the risk of lifelong addiction 19. A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client? a. Total bilirubin b. Urine ketones c. Serum potassium- diuretic that retains potassium= hyperkalemic risk d. Platelet count Rationale ATI PDF p: 146 Pharm Complications: hyperkalemia 20. A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role? a. “I will let the client know that I am available as the interpreter.” b. “I will receive a small fee for interpreting for this client.” c. “I am glad I’m available today, but when I’m not, you can use a family member.” d. “I will let the client know that an interpreter is unavailable during the night shift.” 21. A nurse is performing assessments on newborns in the nursery. Which of the following findings should the nurse report to the provider? a. A two day old newborn who has a respiratory rate of 70 --> 30 - 60 is normal b. A 16 hour old new newborn who has yet to pass meconium- you got 24 hours to pass stool c, A 2 day old newborn who has a small amount of blood tinged vaginal discharge d. A 16 hr old newborn whose blood glucose is 45 mg/dl- 40 - 60 is normal 22. A nurse on an acute unit has received change of shift report for 4 clients which of the following clients should the nurse assess first? Pain pallor pulselessness paresthesia a. A client who is 1 hr postoperative and has hypoactive bowel sounds b. A client who has fractured left tibia and pallor in the affected extremity c. A client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses d. A client who has a elevated AST level following administration of azithromycin 23. A nurse is providing discharge instructions to a client who has a new prescription for haloperidol which of the following adverse effects should the nurse instruct the client to report to the provider? a. Weight gain b. Dry mouth→ anticholinergic effects c. Sedation → s/s neuroleptic malignant syndrome??>> life threatening d. Shuffling gait →A/E EPS: is an indication of parkinsonism and should be reported to t 24. A nurse is planning discharge teaching about cord care for the parents of a newborn which of the following instructions should the nurse plan to include in the teaching? P . 177 ch 26 a. Clean the base of the cord with hydrogen peroxide daily- only with tub and sponge baths b. The cord stump will fall off in 5 days- about 10 - 14 days c. Contact the provider if the cord stump turns black d. Keep the cord stump dry until it falls off Rationale: cord usually falls out within 7 to 10 days. Clean with soap and water. Cord is expected to turn black and dry. 25. A nurse is teaching dietary guidelines to a client who has celiac disease which of the following food choices is appropriate for the client? a. White flour tortillas b. Potato pancakes c. Wheat crackers d. Canned barley soup 26. A nurse is working in acute care mental health facility is assessing a client who has schizophrenia. Which of the following findings should the nurse expect? a. All or nothing thinking b. Euphoric mood c. Disorganized speech d. Hypochondriasis ( anxiety disorder) 27. A nurse is caring for a client who is immobile which of the following interventions is appropriate to prevent contracture? a. Align a trochanter wedge between the clients legs b. Place a towel roll under the clients neck c. Apply an orthotic to the clients foot d. Position a pillow under the client's knees 28. A public health nurse working in a rural area is developing a program to improve health for the local population. Which of the following actions should the nurse plan to take? a. Provide anticipatory guidance classes to parents through public schools b. Have a nurse from the outside the community provide health lectures at the county hospital c. Encourage rural residents to focus health spending on tertiary health interventions d. Launch a media campaign to increase awareness about industrial pollution 29. A nurse in the emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority? a. Below the knee amputation → ESI Level 1 b. 10cm (4 in) laceration → ESI Level 4 c. Fractured tibia → ESI Level 2; if pelvis, femur, or hip and other extremity dislocation then level 1. d. 95% full thickness body burn → 30. A nurse is preparing a change of shift report for an adult female client who is postoperative. Which of the following client information should the nurse include in the report? CONFIRMED a. Hgb 12.8 g/dl - 12- 16 b. Potassium 4.2 meq/l 3.5 - 5.0 meq c. RBC 4.4 million/mm3 d. Platelets 100,000/mm3 - 150,000 - 300,000 risk for bleeding 31. A nurse is admitting a client who has anorexia nervosa. Which of the following is an expected finding? a. Iron 90 mcg/dl b. Prealbumin 10 mcg/dl (normal: 16-40) c. Serum creatinine 0.8 mg/dl d. Calcium 9.5 mg/dl 32. A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the postpartum unit due to a staffing shortage for the shift. Which of the following client assignments should the nurse delegate to the LPN? a. A client who is postoperative following a bowel resection with an NGT set to continuous suction b. A client who has fractured a femur yesterday and is expecting SOB c. A client who sustained a concussion and has unequal pupils d. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs 33. A nurse is caring for a client who is at 41 week of gestation and is receiving oxytocin for labor induction. The nurse notes early deceleration on the fetal heart rate monitor . Which of the following nursing actions should the nurse take ? p . 88 ch 13 maternity a. Continue the monitor the fetal heart rate- - Not a problem- absent or late are a problem however CONFIRMED b. Stop the oxytocin infusion c. Perform a vaginal examination d. Initiate an amnioinfusion 34. A nurse is conducting an initial assessment of a client and noticed a discrepancy between the clients current IV infusion and the information received during the shift report. Which of the following actions should the nurse take? a. Complete an incident report and place it in the client's medical record. b. Compare the current infusion with the prescription in the client's medication record. c. Contact the charge nurse to see if the prescription was changed. d. Submit a written warning for the nurse involved in the incident. 35. A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine ? a. WBC count 2,900 /mm3 - AGRANULOCYTOSIS - 4,800- 15,000 is normal range b. FAsting blood glucose 100 mg/dl c. Hgb 14 g/Dl d. Heart rate 58/min ATI PHARM 116 Complications 36. A nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis C. The client asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate? a. You may breastfeed unless your nipples are cracked or bleeding. b. You must use a breast pump to provide breast milk. c. You must use nipple shield when breastfeeding. d. You may breastfeed after your baby develops his antibiotics. 37. A nurse is caring for a client who has returned to the medical-surgical unit following a transurethral resection of the prostate. Which of the following should the nurse identify as priority nursing assessment after reviewing the clients information? Exhibit. a. Level of consciousness. (priority)- decreased LOC can mean less o2 going to the brain ? b. Skin turgor c. Deep-tendon reflexes d. Bowel sounds 38. A nurse is caring for a client who has hyperthermia .Which of the following actions for the nurse to take ? a. Submerge the adolescent feet in ice water b. Cover the adolescent with a thermal blanket → if hypothermia. c. Administer oral acetaminophen d. Initiate seizure precautions 39. A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include. a. Document the client's conditions every 15 minutes b. Attach the restraints to the beds side rails c. Request a PRN restraints prescription for clients who are aggressive d. Remove the client restraints every 4 hours 40. A nurse in emergency department is caring for a client who has full thickness burn of the thorax and upper torso. After securing the client's airway, which of the following is the nurse's priority intervention? P. 482 ch 75 CONFIRMED a. Providing pain management b. Offering emotional support c. Preventing infection d. Initiating IV fluid resuscitation - they are at risk for hypovolemic shock d/t 3rd spacing 41. A nurse is caring for a client who has cancer and is being transferred to hospice care. The client’s daughter tells the nurse, “I’m not sure what to say to my mom if she asks me about dying.” which of the following responses by the nurse is appropriate? (SATA) A. Hospice will take good care of your mom, so I wouldn’t worry about that. B. Let's talk about your mom’s cancer and how things will progress from here. C. Tell me how you are feeling about your mom dying. D. Tell her not to worry. She still has plenty of time left. E. You sound like you have questions about your mom dying. Let’s talk about it. Rationale: Therapeutic communication 42. A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings follow up care? a. A client who is taking bumetanide and has potassium level of 3.6 mEq/L (normal) b. A client who is scheduled for colonoscopy and taking sodium phosphate c. A client who received a Mantoux test 48 hours ago and has induration d. A client who is taking warfarin and has INR of 1.8 (normal if taking warfarin) 43. 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. Implement the nursing process c. Schedule a time for the home visit d. Contact the family by phone ! 44. A nurse is caring for a client who will undergo a procedure. The client states he does not want the provider to discuss the results with his partner. Which of the following is an appropriate response for the nurse to make? a. You have the right to decide who receives information - b. Your partner can be a great source of support for you at this time c. Is there a reason you don’t want your partner to know about your procedure? d. The provider will be tactful when talking to your partner 45. A nurse is discussing a weight loss with a client who is concerned about losing 6.8 kg (15lb) from an original weight of 9o.7 (200 lb). The nurse should identify the weight of the following total percentage? a. 7.5% b. 15% c. 8.1% d. 13.3% 46. A nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate. Which of the following interventions should the nurse implement? a. Perform fundal massage ( massage if fundus is boggy) b. Pour water from a squeeze bottle over the client’s perineal area. c. Insert an indwelling urinary catheter. d. Apply cold therapy to the client’s perineal area.( warm) 47. A nurse is providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg /hr transdermal patch. Which of the following instructions should the nurse include in the teaching? a. Avoid hot tub while wearing the patch b. Apply patch to your forearm c. Avoid high-fiber foods while taking this medication d. Remove the patch for 8 hours every day to reduce the risk for tolerance. 48. A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of non-blanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan? a. Teach the client to shift his weight every 15 min while sitting (cannot do this because he is paraplegic) b. Place the client upright on a donut-shaped cushion c. Assess pressure points every 24 hr.- must assess d. Turn and reposition the client every 3 hrs. while in bed. - must be q 2 hours in bed, 1 hour in chair. 49. A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? a. We should discuss resources to implement in your daily life b. Let me show you simple relaxation exercises to manage stress. c. Let’s talk about how you can change your response to stress d. We should establish our roles in the initial session. 50. A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods while taking this medication? a. Avocados b. Whole grain bread c. Pepperoni pizza d. Smoked salmon ????? 51. A nurse enters a client’s room and sees a small fire in the client’s bathroom. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all steps) a. Transport the client to another area of the nursing unit (1) b. Activate the facility’s fire alarm system (2) c. Close all nearby windows and doors (3) d. Use the unit’s fire extinguisher to attempt to put out the fire (4) 52. A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect? a. Heightened perceptual field b. Rapid speech -severe c. Feelings of dread d. Purposeless activity 53. A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (Select all that apply.) a. Tremors b. Polydipsia = hyperglycemia c. Acetone Breath odor = DKA d. Diaphoresis e. Inability to concentrate 54. A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding? a. Upper extremity hypotension b. Increased intracranial pressure c. Frequent nosebleeds d. Weak femoral pulses 55. A community health nurse is planning primary prevention activities to reduce the occurrence of abuse. Which of the following strategies should the nurse include in the plan? a. Instruct healthcare professionals to identify abusive situations (screening=secondary prevention) b. Locate financial support to open a shelter for abuse survivors (3rd) c. Teach parenting skills to families at risk for abuse d. Connect abuse survivors with legal counsel (3rd) 56. A nurse and an assistive personnel (AP) are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the AP? a. Documenting the report of pain for a client who is postoperative b. Administering oral fluids to a client who has dysphagia c. Applying a condom catheter for a client who has a spinal cord injury d. Reviewing active range-of-motion exercise with a client who had a stroke 57. A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching? a. “I will take sucralfate with meals three times per day” b. “I will avoid food and beverages that contain caffeine” c. “I will decrease my daily protein intake to 15 grams per day” d. “I will use ibuprofen as needed to control abdominal pain” 58. A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse? a. Offer the client saltine crackers between meals b. Suggest rinsing his mouth with an alcohol-based mouthwash c. Provide humidification of the room air d. Instruct the client on the use of esophageal speech 59. A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel? a. Assess effectiveness of antiemetic medication b. Perform chest compressions during cardiac resuscitation c. Perform a dressing change for a new amputee d. Apply a transdermal nicotine patch- *60. A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication for using lavender? a. The client takes vitamin C daily b. The client has a history of alcohol use disorder c. The client has a history of asthma d. The client takes furosemide twice daily 61. A nurse is caring for a client who has major depressive disorder and a new prescription for amitriptyline. The nurse should monitor for which of the following adverse effects? a. Increased salivation- dry it will cause - anticholinergic effects b. Weight loss c. Urinary retention d. Hypertension- orthostatic hypotension it will cause instead 62. A nurse is conducting a health promotion class about the use of oral contraceptives. Which of the following disorders is a contraindication for oral contraceptive use? a. Asthma b. Hypertension c. Fibromyalgia d. Fibrocystic breast condition 63. A nurse is preparing to witness a client’s signature on a consent form for a colon resection. The nurse should recognize that which of the following information should be provided to the client by the provider before signing the form? (SATA) a. Explain the procedure b. Expected outcome of the procedure c. Potential complications d. Possible alternative treatments e. Cost of the procedure 64. A nurse is providing teaching to a client who will undergo a magnetic resonance imaging (MRI) scan. Which of the following statements is appropriate to include in the teaching? a. “You should not have this procedure if you are allergic to iodine.” b. “You should not have this procedure if you have a tattoo.” c. “The nurse will ask you to wear protective eyewear during this procedure.” d. “The nurse will ask you to remove any transdermal patches prior to the procedure.” 65. A nurse in a provider’s office is reviewing a female client’s medical record during a routine visit. The nurse should recommend increasing dietary intake of which of the following vitamins? (Exhibit) --only tab shown is Tab 3: H&P: postmenopausal, hx DVT and iron deficiency anemia, works indoors, consumes 1- 2 alcoholic beverages per week a. Vitamin D b. Vitamin K c. Vitamin A d. Vitamin B12 66. A nurse is caring for a child who has sickle cell anemia and experiencing vaso- constrictive crisis. Which of the following actions should the nurse include in the plan of care? a. Initiate IV fluid replacement- b. Start a 24-hr urine collection- not the priority c. Give aspirin to reduce pain- acetaminophen or ibuprofen. Asa might lead to reye's disease d. Encourage ambulation- we want to promote rest to decrease 02 consumption 67. A nurse is teaching a parent about safety securing her 3-month-old infant in a car seat. Which of the following images indicates that the parent understands the teaching? B a. B. C and D not shown 68. A nurse is caring for an adult client who has chronic anemia and is scheduled to receive a transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take? P. 249 med surg pdf a. Check the client’s vital signs from the previous shift prior to the initiation of the transfusion assess prior to infusion then be with them for first 15 - 30 minutes. b. Set the IV infusion pump to administer the blood over 6 hr c. Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion d. Administer the blood via a 21-gauge IV needle 69. A nurse is caring for a client who is dissatisfied with the care from the provider and decides to leave the facility against medical advice. After notifying the provider, which of the following actions is appropriate for the nurse to take? a. Summon a security guard b. Explain the risks of leaving c. Complete an incident report d. Notify a social worker Rationale: 70. A nurse is making an initial postpartum home visit. Which of the following client statements should the nurse identify as a manifestation of increased risk for child abuse? a. “I try to respond to the baby quickly .” b. “I think the baby should be sleeping through the night by now. c. “I have several friends who come by to help out with the baby.” d. “I want to meet other parents to see if they are going through the same thing.” 71. A nurse is caring for an infant who has gastroenteritis. Which of the following assessments should the nurse report to the provider? a. Temperature 38 C(100.4 F) and pulse rate 124/min p b. Decreased appetite and irritability c. Pale and 24-hour fluid deficit of 30 mL d. Sunken fontanels and dry mucous membranes 72. A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding, The nurse does not speak the same language as the client . The client partner and a 10 year old child are accompanying her. Which of the following actions should the nurse take to gather the clients information? Request a female translator interpreter through the facility a. Ask a student nurse who speaks the same language to translate b. Have the child translate c. Allow the clients partner to translate 73. A nurse is caring for a client who has pernicious anemia, Which of the following laboratory values should the nurse evaluate effectiveness of the treatment ? A. Folate level B. INR level C. Vitamin b12 level D. Creatinine level 74. A nurse is assigning tasks to assistive personnel(AP). Which of the following tasks should the nurse assign to the AP? a. Suction a new tracheostomy b. Remove an NG tube c. Perform post mortem care d. Change the dressing on an implanted central venous access device 75. A nurse is caring for a client who is postpartum and reports difficulty voiding. Which of the following findings should indicate to the nurse that the client’s ability to eliminate urine from the bladder is restored? a. Two voids of 150 mL each over the past 2 hours= 2 x 30 = 60 mls b. Fundus 2 fingerbreadths above the umbilicus( needs to be below or at the umbilicus) c. Uterine atony( fundus not firm which means possible hemorrhage) d. Fundus firm and to the right of the abdominal midline( fundus not midline, bladder may cause shifting if patient not voiding properly) 76. A nurse is caring for a client who has acute glomerulonephritis .Which of the following should the nurse expect ? a. Polyuria- oliguria b. Hypotension- hypertension c. Hematuria - urinalysis will show red blood cells and protein, also reddish brown col colored urine d. Weight loss - weight gain 77. A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following effects should the nurse include ? p. 50 ch 7 pharm pdf SSRI for social anxiety , PTSD, A. Excessive sweating B. Increased urinary frequency C. Dry cough D. Metallic taste in mouth 78. A nurse is providing teaching to the parents of a newborn about genetic screening. Which of the following statements should the nurse include in the teaching? a. your baby will be given 2 ounces of water to drink prior to the test b. this test will be repeated when your baby is 2 months old c. a nurse will draw blood from your baby’s inner elbow d. this test should be performed after you baby is 24 hours old 79. 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 prior to meals : AVOID Before or AFTER meals b. perform the procedure twice a day c. administer a bronchodilator after the procedure d. hold hand flat to perform percussions on the child 80. a nurse is preparing an inservice for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching? a. placing a yellow bracelet on a client who is at risk for falls→ correct approach; yellow bracelet indicates fall risk b. administering potassium via IV bolus c. documenting communication with a provider in the progress notes of the client’s medical record d. leaving a nasogastric tube clamped after administering oral medication → 81. A nurse in a clinic is assessing a client who reports frequent headaches. Identify the area the nurse should palpate to check the client’s maxillary sinus for tenderness. R: p147 ati funds Palpate the maxillary sinuses by pressing upward at the skin crevices that run from the sides of the nose to the corner of the mouth. 82. A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage? a. Take pancrelipase b. Complete oral hygiene c. Eat a meal d. Use an albuterol inhaler 83. A nurse is caring for a client following a cardiac catheterization through the left groin. Which of the following actions should the nurse take? P . 164 ch 27 medsurge a. Monitor the dorsalis pedis pulse every 15 minutes → circulation b. Maintain strict bedrest for first 12 hr- only for prescribed time, older adults usally are up to 4 hours. c. Keep the client NPO for 24 hr- doesn’t say anything about restrictions AFTER the procedure , and npo b4 the procedure is uP to 8 hours. d. Place the client in Fowler’s position- supine they must be 84. A nurse is caring for a client who has depression and is experiencing loss of appetite. Which of the following actions should the nurse take? a. Offer high-calorie, high protein snacks to the client b. Recommend the family provide the client privacy during meals c. Weigh the client once each day d. Encourage the client to eat foods selected by the dietitian 85. A nurse is caring for a client who requests to ambulate in the hallway with his own clothing. The nurse is demonstrating which of the following ethical principles when respecting the client's decision to wear his own clothing ? a. Non maleficence b. Veracity c. Autonomy d. Justice R: p47 ati leadership Autonomy: The ability of the client to make personal decisions, even when those decisions might not be in the client’s own best interest 86. A nurse in an emergency department is caring for a toddler who has burns following a house fire. Which of the following actions should the nurse take first ? A. Check the mouth for smooth and smoky breath - airway obstruction via foreign body B. Calculate the fluid replacement based on vital signs and urinary output C. Determine the location and depth of burns D. Administer antibiotics to prevent sepsis. 87. A nurse is assessing a client who had heart failure is taking furosemide. Which of the following findings should the nurse monitor ? a. Hyponatremia- loop diuretic (Lasix) - wherever water goes sodium and potassium will follow b. Hyperkalemia c. Hypercalcemia d. hypoglycemia 88. a nurse Is caring for a client who weighs 75 kg. the client has a prescription from a dietician to decrease calorie intake by 500 cal/day for 25 weeks produce a weight loss of 1 pound per week. What is the expected goal weight for the client in pounds at the end of the 25 weeks? (round the answer to the nearest whole number. Use leading zero if it applies. No trailing Zero) 140??(not sure) pounds 1 lb per week x 25 week= 25 lbs 75 x 2.2= 165 lbs 165 lbs-25 lbs=140 lbs or 63.6 kg (64 kg) 89. a nurse is providing discharge teaching about circumcision care to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? a. I will change my baby’s diaper at least every 4 hours b. I will apply an ice pack to my baby’s penis twice daily to decrease swelling c. I will wash the penis with soap and warm water until the circumcision has healed d. I will apply topical lidocaine following each diaper change Teach the parents to keep the area clean. 90. a home health nurse is caring for an adult client who reports, “I keep coughing when I try to swallow my food, but not at other times.” Which of the following actions should the nurse take? a. encourage the client to increase fluid intake b. initiate a consultation with a speech→ language pathologist; swallow eval c. instruct the client that this is due to increased salivary flow that occurs with aging d. recommend an antitussive 30 minutes prior to each meal R: p56 AMS Refer to speech language therapist for dysarthria and dysphagia. 91. A nurse is caring for a client who is insulin dependent and is undergoing tests to determine if his blood glucose is being adequately controlled. The nurse should identify that which of the following laboratory values is the best indicator of adequate blood glucose control? A. Postprandial blood glucose 190 mg/dl B. Fasting blood glucose 60 mg/dl C. HbA1c 6.5% D. Hct 42% 92. A nurse is planning to administer Atenolol to a client. Which of the following should the nurse assess prior to administering the medication? A. BUN B. Blood pressure C. Respiratory rate D. aPTT 93. A nurse is orienting a newly licensed nurse while caring for clients who are in labor. Which of the following pain management strategies by the newly licensed nurse requires intervention? A. Encouraging the client to use jet therapy on her lower back for 1 hr B. Placing a transcutaneous electrical nerve stimulation (TENS) unit on a client’s abdomen C. Using effleurage on a client’s lower abdomen D. Instructing a client’s partner how to apply counterpressure to the client’s sacral spine for 30 min 94. A nurse has identified tasks to delegate to a group of assistive personnel (AP) after receiving change-of-shift report. Identify the sequence of steps the nurse should follow when delegating tasks to the APs. A. Review the skill level of and qualifications of each AP 1 B. Communicate appropriate tasks to the APs with specific expectations 2 C. Monitor progress of task completion with each AP 3 D. Evaluate the APs’ performance of each task 4 95. 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 should take antibiotics when I have a virus.” B. “I should wash my hands for 10 seconds with hot water after working in the garden.” C. “I can clean my cat’s litter box during my pregnancy.” D. “I can visit my nephew who has chickenpox 5 days after the sores have crusted.” 96. A nurse I caring for a school-age child who is 2 hr postoperative following a cardiac catheterization. The nurse observes blood on the child’s dressing. Which of the following actions should the nurse take? A. Apply intermittent pressure 2.5 cm (1 in) below the percutaneous skin site. B. Apply continuous pressure 2.5 cm (1 in) below the percutaneous skin site. C. Apply continuous pressure 2.5 cm (1 in) above the percutaneous skin site. D. Apply intermittent pressure 2.5 cm (1 in) above the percutaneous skin site. 97. A nurse is reviewing the medical record of a client who has a prescription for intermittent heat therapy for a foot injury. Which if the following findings should the nurse identify as a contraindication for heat therapy? A. Phlebitis B. Abdominal aortic aneurysm C. Osteoarthritis D. Peripheral neuropathy 98. A nurse is providing teaching to a client who is to undergo a cardiac catheterization. Which of the following findings is expected during the procedure? A. Sensation of skin warmth B. Headache C. Increased salivation D. Numbness and tingling of the extremities 99. A nurse is transcribing new medication prescriptions for a group of clients. For which of the following prescriptions should the nurse contact the provider for clarification? A. Lorazepam .5 mg PO one tablet daily B. Hydrochlorothiazide 12.5 mg PO BID C. Triamcinolone acetonide 100 mcg/inhalation two puffs TID D. Zolpidem 10 mg PO one tablet at bedtime 100. A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? A. Swelling of the face B. Urinary frequency C. Faintness upon rising D. Bleeding gums 101. A nurse is providing care for a client who has esophageal cancer and has received radiation therapy. Which of the following finding should the nurse identify as the priority? A. Excoriation of the skin on the neck and chest B. Dysphagia C. Client reports a pain level of 6 on scale from 0-10 D. Xerostomia 102. A nurse is assessing a client who is 2 hrs postpartum for uterine atony. Which of the following action should the nurse take? A. Monitor the client’s urinary output B. Check the client VS C. Evaluate the client's pain level D. Palpate the client’s fundus 103. A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include? A. “This type of seizure can be mistaken for daydreaming” B. “The child usually has an aura prior to onset” C. This type of seizure last 30-60 sec” D. “This type of seizure has a gradual onset” 104. A nurse in a surgical suite is planning care for a client who requires surgery and has a latex sensitivity. Which of the following is appropriate for this client? A. Disinfect and powder any latex products before use B. Tape stockinet over monitoring device and cords C. Schedule the client as the last surgery of the day D. Remove poopsocks from the IV 105. A nurse is reviewing the medical record of a client. The nurse should identify that the client is at risk for which of the following complication. A Dumping syndrome B Ketoacidosis C Hepatotoxicity D Thyroid storm 106. A nurse is caring for a client who has lung cancer and has a sealed radiation implant. Which of the following action should nurse take? (SATA) A. Place the client in a semi-private room B. Wear a lead apron when providing care C. Limit visitors to 30 mins D. Instruct visitors who are pregnant to remain 3 ft from the client E. Close the door to the client's room 107. A CN (charge nurse) is providing teaching for group of newly licensed nurse about grieving process. Which of the following information should the CN include in the teaching? A. Client can expect to have feeling of hopelessness B. Client might feel guilt over some aspect of their loss C. Client will experience anhedonia D. Client will experience low self-esteem 108. A client who is pregnant voice her concern that her 3y/o son will feel left out one the newborn arrives. Which of the following statements by the nurse is appropriate? A. Offer your son a gift when the baby receives one B. Move your son to a toddler bed when the baby arrives C. Tell your son to kiss the baby D. Teach your son to change the baby diapers - not the answer 109. A nurse is obtaining a nutritional health hx on a client who reports problems with constipation. Which of the following should the nurse identify as a cause of constipation? A. Following high-fiber diet B. Currently taking probiotics C. New prescription for an iron supplement D. Intolerance to lactose 110. A nurse is assessing a newborn who has patent ductus arteriosus. Which of the following findings should the nurse except? A. Increase PaO2 B. Hypoglycemia C. Board-like abdomen D. Bounding pulse 111. 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. Measure the client’s urine output every hour. - monitor for toxicity. b. Restrict the client’s total fluid intake to 250ml/hr. c. Monitor the FHR via Doppler every 30 min d. Give the client protamine if sign of magnesium sulfate toxicity occur. . 112. A nurse is caring for a client who has end stage kidney disease. 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. Hypertension b. Primary glaucoma c. Osteoarthritis d. Amputation 113. A nurse is caring for a client who has COPD and is 5kg (11lb) below her ideal body weight. The client experiences shortness of breath when eating. Which of the following actions should the nurse take? a. Administer a bronchodilator following meals. b. Request non gas forming foods from the dietary department c. Limit the client’s food consumption between meals. d. Arrange for a low protein diet. HIGH PROTEIN. 114. A nurse in a provider’s office is reviewing the laboratory results of a group of clients. The nurse should identify that which of the following sexually transmitted infectious disease that should be reported to the state health department? a. Candidiasis b. Herpes simplex virus c. Human papillomavirus d. Chlamydia 115. A nurse is reviewing the laboratory findings of a client who is receiving IV infusion of insulin. The client’s lab findings reveal a potassium level of 5.5 mEq/L, BUN of 15 mg/dL, and a creatinine level of 1 mg/dL. Which of the following interventions is appropriate for the nurse to take? a. Place a cardiac monitor on the client b. Stop the IV infusion of insulin c. Administer oral potassium to the client- potassium is already high d. Initiate a 24 hr urine collection . 116. A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching? a. I can go jogging after 2 weeks. -Avoid vigorous activities. b. I can lift objects that are less than 10 seconds. -avoid lifting more than 5pounds. c. I can resume activities, such as sewing. d. I should bend at the waist when putting on my shoes. -Avoid bending at the waist level. 117. A nurse is planning to administer vancomycin IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin? a. Give the dose over 60 min b. Administer the medication undiluted c. Obtain trough level 30 min after the medication infusion d. Inject 1% lidocaine prior to each dose 118. A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching ? a. Take magnesium hydroxide for indigestion -not for pts with CKD or dialysis. b. Eat 1g/kg of protein per day c. Drink at least 3L of fluid daily -too much fluid d. Consume foods high in potassium -low potassium diet 119. A nurse is delegating tasks to an assistive personnel group of clients. Which of the following statements should the nurse make? a. Take the client in room 106 to radiology b. Take the vital signs of the clients on the side of the unit c. Tell me the standing weight of the client in room 102 before breakfast d. The client in room 109 has spilled his water pitcher Rationale: right direction/communication. Leadership. 120. A nurse is caring for a client who has heart failure and is receiving a continuous IV infusion of low dose dopamine. Which of the following findings is the highest priority? a. Erythema 5 cm (2in) above the IV site b. Blood pressure 92/68 mm Hg - c. Urine output 35mL/hr d. Pedal pulse of +1 bilaterally 121. A nurse is providing teaching about the use of crutches using a three-point gait to a client who has tibia fracture. Which of the following actions by the client indicates an understanding of the teaching? A. Positioning both hands on the grips with his elbows slightly flexed B. Supporting his body weight while leaning on the axillary crutch pads (Support body weight using both Crutches when shifting weight) C. Stepping with his affected leg first when going up stairs (Unaffected First) D. Moving both crutches with the stronger leg forward . 122. A nurse is assessing a 24-month-old toddler during a well-child visit. Which of the following developmental tasks should the toddler be able to perform? A. Hop on one foot B. Kick a ball forward C. Climb Stairs with alternate feet D. Ride a tricycle 123. A case manager is meeting with a client who asks about using alternative therapies to manage her rheumatoid arthritis. Which of the following statements should the nurse make? A. Im sure you can find alternative remedies through an online support group B. If there are therapies available to you, your provider will tell you about them C. Feel free to try whatever therapies that fit within your personal belief system D. We can review some information to help you select a safe alternative practitioner. ● Facilitating conti ● Improving efficiency of care and utilization of resources 124. A nurse is assessing a client following a ischemic stroke. Which of the following findings is the priority for the nurse to report to the provider? A. The client reports a metallic taste in his mouth B. A client reports a decreased appetite C. The client coughs after swallowing D. The client has poor fitting dentures 125. A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate effectiveness of the procedure? A. Compare the client's current weight with preprocedure weight. B. Check the client's serum albumin levels C. Examine for leakage at thes site of the procedure D. Confirm that the client is able to urinate 126. A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan? A. Swaddle the newborn with this leg extended. B. Maintain eye contact with the newborn during feedings. C. Minimize noise in the newborn environment D. Administer naloxone to the newborn ● Reduce environmental stimuli (decrease lights, lower noise level). 127. A newly licensed nurse is reviewing the role of a nurse in disaster planning. Which of the following is an activity a nurse should engage in to assist in disaster preparedness? A. Participate in community drills and mock events. B. Vaccinate susceptible children and adults against smallpox C. Assess types, levels and scopes of disasters. D. Make quarantine preparations for those exposed to anthrax Rationale: Assess First 128. A nurse is completing an admission assess for a client who has narcissistic personality disorder. Which of the findings should the nurse expect? A. Ritualistic behavior (OCD) B. Exhibits separation anxiety (Dependent) C. Preoccupied with aging D. Suspicious of others. (Paranoid) 129. A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan? A. Withdraw the client's TV privileges if he does not attend group therapy B. Place the client in seclusion when exhibits signs of anxiety C. Encourage the client to take frequent rest periods. D. Encourage the client to spend time in the day room 130. A nurse is obtaining a client’s medical history before initiating 1000 ml of 0.9% NaCl with 20 mEq/L KCl IV to correct hypokalemia. Which of the following findings is a contraindication to the client receiving this IV solution? A. Severe renal impairment. (Stage IV Kidney Disease) B. Chronic alcohol use disorder C. Multiple sclerosis D. Advanced cardiac disease. 131. A nurse is auscultating heart sounds of an adult client experiencing dyspnea. The nurse hears a soft, turbulent sound between beats at the left midclavicular line in the fifth intercostal space. Which of the following is an appropriate documentation of the findings? a. Fourth heart sound at the aortic area b. Murmur at the mitral area c. Third heart sound at the tricuspid area d. Pericardial friction rub at the pulmonic area 132. A nurse is teaching a client who has a newly documented latex allergy. Which of the following statements by the clients indicates an understanding of the teaching? a. I will remove dairy products from my diet b. I will remove peanuts from my diet c. I will remove bananas from my diet d. I will remove gluten from my diet ● People allergic to latex also allergic to avocado, banana, chestnut, kiwi, passion fruit, plum, strawberry, tomato 133. A nurse is obtaining a medical history from a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should report which of the following conditions is a contraindication for the use of metformin? a. Seizure disorder b. Polycystic ovary syndrome c. Renal insufficiency d. Gluten intolerance 134. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? a. Contractions - b. Vomiting c. Hypertension d. Epigastric pain -google 135. A nurse on a surgical pediatric care unit receives report prior to providing care for a group of clients. Which of the following clients should the nurse assess first? a. A 15 year old who is 6 hr postop following a herniorrhaphy and reports pain at the IV site b. 3 month old who is 1 day postop following cleft lip repair and has a pulse of 120 c. 12 year old who is 2 days postop following an appendectomy and is refusing to ambulate d. 8 year old client who is 12 hr postop following a tonsillectomy and is experiencing frequent swallowing - bleeding 136. A nurse is teaching a client how to perform kegel exercises. Which of the following client statements indicates understanding of the teaching? a. I will alternately contract and relax my gluteal muscles b. I will perform the exercises once each day before bed c. I will try to hold my urine for a little after i first feel the urge to urinate d. I will determine which muscles to contract by stopping and starting my stream of urine 137. A nurse is providing prenatal teaching for a client who is scheduled for an amniocentesis. Which of the following statements indicates that the client understands the teaching? a. I need to have an enema before the test b. I should urinate before the test c. I will lie on my left side during the test d. I will drink an oral glucose solution during the test 138. A nurse in an emergency department is caring for a client who reports cocaine use 1 hr ago. Which of the following findings should the nurse expect? a. Memory loss b. Slurred speech c. Elevated temperature d. hypotension ● Dizziness, tremor, blurred vision, seizures, fever, tachycardia, hypertension 139. A nurse is assessing the heart sounds of a client who has acute pericarditis. Which of the following clinical manifestations is an expected finding for this client? a. Report of occipital headache b. Scratchy, high pitched sound upon chest auscultation c. ECG demonstrates a depressed ST segment d. White, diffuse peritonsillar pustules 140. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include? a. Increase intake of foods high in gluten b. Consume food high in bran fiber c. Sweeten foods with fructose corn syrup d. Increase intake of milk product ● Limit gas forming foods, caffeine, alcohol. Encourage high fiber and fluids 141.A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client’s coccyx and abrasions around the wrists. Which of the following actions should the nurse take to address the suspicions of elder abuse? a. Inform the transferring agency of the client’s condition. b. Privately interview the client about her condition. c. Notify risk management d. Contact the family regarding the client’s condition. 142.A nurse is caring for a client following a stroke. The client has right-sided weakness and facial drooping. Which of the following nursing actions is the priority? a. Maintain NPO status for client(ABC) b. Change client's position every 2 hours c. Perform range-of-motion exercises to client’s extremities. d. Place the clients right hand in supination position. 143. A community health nurse is teaching a client who has type 1 diabetes mellitus and is 10 weeks of gestation about managing diabetes during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? a. “I will decrease my protein intake during the third trimester”( increase protein for basic growth) b. “I will need to increase my insulin doses later in my pregnancy” c. “I will increase my carbs at breakfast and limit them the rest of the day” d. “I will decrease my calorie consumption during the first trimester”(increase calorie) 144.A home health nurse is preparing to assess a client who reports tingling around the mouth and laxative use at least once daily. Which of the following assessments should the nurse perform first? a. Test the client for Trousseau’s sign b. Assess the client’s skin turgor c. Check the client’s motor strength d. Measure the client’s pupil size 145. A nurse is teaching a client who has an ileostomy about the care of his stoma site. Which of the following statements by the client requires further teaching? a. “I should clean my stoma with warm water”( can use low ph soap and water) b. “ My stoma should be bright pink or red”(pink,red and moist) c. “I should change the stoma pouch every day” d. “I should cut my pouch opening ⅛ inch larger than my stoma”(allow expansion) Rationale: ATI ostomy care video pouches good for up to 2-7 days, empty at ¼ or ½ full. 146.A nurse is assessing a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse recognize as a result of magnesium sulfate toxicity? a. Hyporeflexia b. Tachypnea( bradypnea, less than 12/min) c. Pruritus( sign of allergic reaction) d. Polyuria (oliguria, less than 30 ml/hr) 147.A nurse is planning to administer ampicillin 100 mg/kg/day in divided doses every 12 hours to a newborn who weighs 4.34 kg(9.5 lbs). Available is ampicillin 125mg/ml. How many milliliters should the nurse administer per dose? ( Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero) Answer is 1.7 mL per dose Rationale: 100mg X 4.34 kg= 434 mg/day 434mg/125mgX1=3.472/day 3.472/2= 1.736 148.A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make? a. “Your desire to be an organ donor must be documented in writing” 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 name cannot be removed once you are listed on the organ donor list 149.A nurse is admitting a client who has acute heart failure. Which of the following prescriptions from the provider should the nurse anticipate? a. Administer enalapril 2.5 mg PO twice daily b. Ambulate the client every 4 hr while awake(bedrest) c. Provide the client with 4 g sodium diet( d. Infuse 0.9% sodium chloride 500 mL IV bolus over 1 hr 150.A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take during collection? a. Drain the specimen from the drainage bag(not sterile use the port for culture and UA) b. Clamp the catheter distal to the injection port c. Collect 2 mL of urine for each specimen d. Obtain the urinalysis specimen before the culture specimen 151. A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitor the client for which of the following manifestations? A. Orthostatic Hypertension B. Dependent Edema C. Decreased Hematocrit D. Neck Vein Distension 152. A nurse is devdeloping an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? A. The client is overly concerned about minor details. B. The client exhibits impulsive behavior. C. The client is exceptionally clingy to others. D. The client may act seductively.- histrionic 153. A nurse is assessing a client who is 36 weeks of gestation. Which of the following findings should the nurse report to the provider? A. 3+ deep tendon reflexes (common finding in women with preeclampsia and does not require action unless there are symptoms of magnesium toxicity.) B. Protruding Hemorrhoids C. Urinary Frequency (expected) D. Supine Hypotension Rationale: 154. A nurse is administering an analgesic to a client who has a chest tube. The provider is preparing to discontinue the chest tube before the medication has taken affect. Which of the following actions should the nurse prepare to take first? A. Inform the provider of the time of the last dose of pain medication. B. Document the sequence of events as they occur. C. Provide non-pharmacological pain management interventions. D. Instruct the client about the steps of the procedure. 155. A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report? A. The client was intubated without complications. B. The estimated blood loss was 250 milliliters. C. There was a total of 10 sponges used during the procedures. D. The client is a member of the board of directors. 156. A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching? A. “You can add the medication to a half-cup of your child’s favorite juice.” B. “Repeat the dose if your child vomits within 1 hour after taking the medication.” C. “Limit your child’s potassium intake while she is taking this medication.” D. “Have your child drink a small glass of water after swallowing the medication.” 157. A nurse is assessing a client’s pulmonary artery wedge pressure (PAWP). The nurse should recognize that an elevated PAWP indicates which of the following complications? A. Left ventricular failure B. Cardiogenic shock C. Hypovolemia D. Hypotension 158. 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 has COPD and a respiratory rate of 44/min B. A client who has cancer with a sealed implant for radiation treatment. C. A client who is 1 day postoperative following a vertebroplasty D. A client who is receiving heparin for deep vein thrombosis. 159. A nurse is caring for four clients who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention before surgery? A. Fasting blood glucose 108 mg/dl (WNL) B. WBC 9,800/mm (WNL) C. Creatinine 0.9 mg/dl (WNL) D. Potassium 5.2 mEq/L . 160. A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching? Paul for 158 would u pick D ? A. Engage the client in activities that increase sensory stimulation. B. Discourage physical activity during the day. C. Establish a toileting schedule for the client. D. Use clothing with buttons and zippers. 151. A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitor the client for which of the following manifestations a. Orthostatic hypotension - b. Dependant Edema- fluid volume excess c. Decreased Hematocrit - fluid volume excess d/t super diltion d. Neck vein distention - fluid volume excess 152. A nurse is developing an in service about personality disorders Which of the following information should the nurse include when discussing borderline personality disorder? a. The client is overly concerned about minor details b. The client exhibits impulsive behavior - spending money giving away money or possessions. c. The client is exceptionally clingy to others d. The client might act seductively 153. A nurse is assessing a client who is at 36 weeks gestation. Which of the following findings should the nurse report to the provider ? a. 3+ deep tendon reflexes -preeclampsia b. Protruding hemorrhoids c. Urinary frequency ch 4 p. 21 maternal d. Supine hypotension - teach them side lying position 154. A nurse is administering an analgesic to a client who has a chest tube . The provider is preparing to discontinue the chest tube before the medication has taken effect. Which of the following actions should the nurse take first ? a. Inform the provider of the time of the last does of pain medication b. Document the sequence of events as they occur c. Provide non pharmacological pain management interventions d. Instruct the client about the steps of the procedure 155. A nurse in a PACU is transferring care of a client to a nurse on the medical surgical unit. Which of the following statements should the nurse include in the hand off report ? a. The client was intubated without complication b. The estimated blood loss was 250 milliliters c. There was a total of 10 sponges used during the procedure - what kind d. The client is a member of the board of directors 157. A nurse is assessing a clients PAWP. The nurse should recognize that an elevated PAWP indicates which of the following complication? a. Left ventricular failure b. Cardiogenic shock c. Hypovolemia d. Hypotension 158. A charge nurse on a medical surgical unit is assisting with the emergency responses plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current client should the nurse recommend for early discharge ? a. A client who has COPD and a respiratory rate of 44/ min - RR is too high out of range b. A client who has cancer with a sealed implant for radiation therapy - an implant is inside them, and its active c. A client who is 1 day postoperative following a vertebroplasty d. A client who is receiving heparin for deep vein thrombosis - as said in class Heparin for Hospital and that other Coumadin for home 159. A nurse is caring for four client who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention before surgery ? a. Fasting blood glucose 108 mg/ dl b. WBC 9,800 mm3 > 4,800 is normal c. Creatnine 0.9 mg/dl , < 1.0 is normal d. Potaissium 5.2 meq / L 3.5 - 5.0 = 160. A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching ? a. Engage the client in activities that increase sensory stimulation. b. Discourage physical activity during the day c. Establish a toileting schedule for the client d. Use clothing with buttons and zippers 161. A charge nurse is preparing to lead negotiations among nursing staff due to conflict about overtime requirements. Which of the following strategies should the charge nurse use to promote effective negotiation? a. Identify Solutions prior to negotiation b. personalize the conflict c. Attempt to understand both sides of the issue d. Focus on how the conflict occurred Assess the situation first prior to trying to solve it. 162. A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at the peripheral IV site. Which of the following actions should the nurse plan to take? a. Insert a new IV catheter distal to the discontinued IV site b. apply pressure dressing at the IV site c. Please a warm moist compress on the site d. Express drainage from the IV site and send it to be cultured Phlebitis is characterized by pain, increased skin temperature, and redness along the vein. It is commonly treated by discontinuing the IV line and applying a moist, warm compress over the area. 163. A nurse is preparing to administer three medications to a client who is receiving continuous enteral tube feeding through an NG tube. Which of the following actions is appropriate for the nurse to take? a. ADD medication directly to enteral feeding - not without crushing them first b. Dissolve the medications together- some medications can mix others can’t c. Use a syringe to allow the medications to Flow by gravity d. Flush the NG tube with 5 ml water- 10ml 164. The nurse is caring for a client who has histrionic personality disorder. Which of the following findings should the nurse expect? a. Repeated acts of unlawful Behavior b. Suspicious demeanor c. Seductive Behavior d. Lack of remorse 165. A nurse in a prenatal Clinic is teaching a client about non pharmacological pain management during labor. Which of the following statements by the client indicates an understanding of the teaching? a. My nurse can teach me biofeedback at the beginning of labor- biofeedback would be taught earlier to control other pain, not pain of labor b. A transcutaneous electrical nerve stimulator will help with pelvic pressure- This would mess with the readings of the pt and baby c. The nurse will initiate acupuncture when I arrive at the unit - Needles during labor no. d. I can use my ultrasound picture as a focal point during contractions 166. A nurse is assessing a client Telemetry strip. Which of the following findings should the nurse report to the provider? a. Heart rate 98 per minute - wnr b. ST segment elevations_ Remember this could possibly lead to infarctions c. 2 PVCs per minute d. Widened P wave 167. A nurse is observing a newly licensed nurse who is administering Total parenteral Nutrition tpn to a client. Which of the following actions by the newly licensed nurse indicates a need for the nurse to intervene? a. Plans for a check of the clients fingerstick glucose every 6 hours b. Schedules a bag and tubing change for 24 hours after the start of the infusion- ok c. Uses the tpn IV tubing to administer the clients next dose of antibiotic d. Increases the tpn infusion rate each hour until the prescribed rate is achieved 168. A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. which of the following group facilitation techniques should the nurse include in the teaching? a. Yield in situations of conflict to maintain group Harmony - If conflict arises it is your responsibility to contain it b. Share personal opinions to help influence the group's values -your focus is having group share their personal thoughts and feelings to facilitate discussion c. Use modeling to help the clients improve their interpersonal skills d. Measure the accomplishments of the group against a previous group - no comparison 169. A nurse is assessing a client's respirations which of the following actions should the nurse take? a. Assess respirations before counting radial pulsations -either or is fine b. Multiply the number of respirations in 15 seconds by 4 - short way to do it, not necessarily the right way c. Inform the client that has breaths will be counted- may raise or lower breath rate due to fear d. Count respirations for 1 minute if the rhythm is irregular 170. A client’s partner tells a staff nurse that he overhears laboratory staff discussing the result of the clients biopsy report while on the elevator. Which of the following actions should the nurse take? a. Report the information to the charge nurse b. review confidentiality policies with laboratory employees- would be the job of the Facility manager or someone who audits or teaches HIPAA stuff c. contact the laboratory manager regarding the situation - you are not high enough up the chain to do that d. Notify the facilities legal department - no need to go that far 171. A nurse is assessing a client who requests an oral contraceptive. Which of the following findings in the client’s medical history should the nurse identify as a contraindication for the use of a combination oral contraceptive? a. Concurrent use of levothyroxine b. Allergy to penicillin c. Recurrent urinary tract infections d. Migraines with aura Rationale: MN RM 10.0 Ch.1 p.6; Exacerbates conditions affected by fluid retention, such as migraine, epilepsy, asthma, kidney, or heart disease. 172. A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the following clients should the nurse see first? a. A client who is at 36 weeks of gestation and has a biophysical profile score of 8 b. A client who has pregestational diabetes mellitus and an HbA1c of 6.2% c. A client who is at 28 weeks of gestation and reports leukorrhea d. A client who has preeclampsia and reports a persistent headache 173. A nurse is planning care for a client who is scheduled to have a paracentesis. Which of the following actions should the nurse include in the plan of care? a. Instruct the client to empty her bladder prior to the procedure. b. Position the client over an overbed table prior to the procedure. c. Administer 1 L dextrose 5% in water IV bolus prior to the procedure. d. Initiate NPO status 4 hr prior to the procedure. . 174. A nurse is caring for a client who is in active labor and notes the FHR baselines has been 100/min for the past 15 min. The nurse should the identify which of the following conditions as a possible cause of fetal bradycardia? a. Maternal hypoglycemia b. Chorioamnionitis c. Fetal anemia d. Maternal fever 175. A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states, “I don’t know what to do. Everything has been happening so quickly.” Which of the following responses by the nurse is therapeutic? a. “You should make sure your partner takes the prescribed medication.” b. “Why do you think your partner’s symptoms are progressing so quickly?” c. “You did the right thing by bringing your partner in for treatment.” d. “Can you talk about what was happening with your partner at home?” 176. A nurse is assessing a client who is prescribed valproic acid. Which of the following laboratory tests should the nurse monitor? a. Arterial blood gas b. Serum potassium c. Liver function test d. Serum creatinine 177. A nurse is providing a preoperative teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching? a. “Continuous PCA infusion is designed to allow fluctuating plasma medication levels.” b. “The PCA will deliver a double dose of medication when you push the button twice.” c. “You should push the button before physical activity to allow maximum pain control.” d. “You can adjust the amount of pain medication you receive by pushing on the keypad.” 178. A nurse is preparing to catheterize a toddler for a urine culture. Which of the following is an appropriate action for the nurse to take? a. Discard the first 10 mL of urine. b. Apply EMLA cream prior to the procedure. c. Obtain a 12 French catheter. d. Don sterile gloves prior to the procedure. 179. A nurse is reviewing the laboratory levels of a client who is having elective surgery. Which of the following levels should the nurse report to the provider? a. Potassium 3.2 mEq/L 3.5 - 5.0 is normal b. BUN 16 mg/dL (Normal 10-20) c. PT 12.2 seconds (Normal 11-14) d. Fasting blood glucose 103 mg/dL 180. A nurse is admitting a client who has schizophrenia. The client states, “I’m hearing voices.” Which of the following responses is the priority for the nurse to state? a. “How long have you been hearing the voices?” b. “What are the voices telling you?” c. “Have you taken your medication today?” “I realize the voices are real to you, but I don’t hear anything.”- ATI COMPREHENSIVE EXIT FINAL 1) A nurse in an emergency department completes an assessment on an adolescent client that has conduct disorder. The client threatened suicide to teacher at school. Which of the following statements should the nurse include in the assessment? a) Tell me about your siblings b) Tell me what kind of music you like c) Tell me how often do you drink alcohol d) Tell me about your school schedule 2) *A nurse is observing bonding to the client her newborn. Which of following actions by the client requires the nurse to intervene? a) Holding the newborn in an en face position b) Asking the father to change the newborn's diaper c) Requesting the nurse take the newborn nursery so she can rest d) Viewing the newborn’s actions to be uncooperative 3) A nurse is caring for client who is taking levothyroxin. Which of the following findings should indicate that the medication is effective? a) Weight loss (this drug acts as T4 and will normalize the effects of hypothyroidism) b) Decreased blood pressure c) Absence of seizures d) Decrease inflammation 4) A nurse is planning discharge teaching for cord care for the parent of a newborn. Which instructions would you include in the teaching? a) Contact provider if the cord still turns black (it’s going to turn black) b) Clean the base of the cord with hydrogen peroxide daily (clean with neutral pH cleanser) c) Keep the cord dry until it falls off (cord should be kept clean and dry to prevent infection) d) The cord stump will fall off in five days (cord falls off in 10-14 days) 5) A nurse is assessing a client in the PACU. Which of the following findings indicates decreased cardiac output? a) Shivering b) Oliguria c) Bradypnea d) Constricted pupils 6) A nurse is assisting with mass casualty triage: explosion at a local factory. Which of the following client should the nurse identify as the priority? a) A client that has massive head trauma b) A client has full thickness burns to face and trunk c) A client with indications of hypovolemic shock d) A client with open fracture of the lower extremity 7) A nurse is a receiving report on four clients. Which of the following clients should the nurse assess first? a) A client who has illeal conduit and mucus in the pouch b) Client pleasant arteriovenous additional vibration palpated 1 of 28 c) A client whose chronic kidney disease with cloudy diasylate outflow d) A client was transurethral resection of the prostate with a red tinged urine in the bag 8) A nurse is caring for a client just received the first dose of lisinopril. The following is an appropriate nursing intervention? a) Place’s cardiac monitoring b) Monitor the clients oxygen saturation level c) Provide standby assist with the client from bed d) Encourage foods high in potassium 9) A nurse is caring for a client who is in labor and his seat is receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. Which the following should the nurse expect? a) Feta hypoxia b) Abrupto placentae c) Post maturity d) Head Compression 10) A nurse is caring for a client who has chronic kidney disease. The nurse should identify which of the following laboratory values as in an indication for hemodialysis? a) glomerular filtration rate of 14 mL/ minute b) BUN 16 mg/DL c) serum magnesium 1.8 mg mg/dl d) Serum phosphorus 4.0 mg/dL 11) A nurse is caring for an infant who has a prescription for continuous pulse oximetry. The following is an appropriate action for the nurse to take? a) Placed infant under radiant warmer b) Move the probe site every 3 hours c) Heat the skin one minute prior to placing the program d) Placed a sensor on the index finger 12) A nurse in a mental health facility receives a change of shift report on for clients. Which of the following clients should the nurse plan to assess first? a) Client placed in restraints to the aggressive behavior b) A new limited client pleasures history of 4.5 kg weight loss in the past two months c) Client is receiving a PRN dose of health heard all two hours ago for increased anxiety d) Applied he’ll be receiving his first ECT treatment today 13) A nurse working at the clinic is teaching a group of clients who are pregnant on the use of nonpharmacological pain management. Which of the following statements by the nurse is an appropriate description of the use of hypnosis during labor? a) Hypnosis focuses on the biofeedback as a relaxation technique b) Hypnosis promotes increased control of her pain perception during contractions c) Hypnosis uses therapeutic touch to reduce anxiety during labor d) Hypnosis provides instruction to minimize pain 2 of 28 14) A nurse in a County Jail health clinic is leading group therapy session. A client who was incarcerated for theft is addressing the group. Which of the following is an example of reaction formation? (rxn formation is when you use opposite feelings; ex: being super nice to someone you dislike) a) I steal things because it’s the only way I can keep my mind off my bad marriage b) I can’t believe I was accused of something I didn’t do c) I don’t want talk about my feelings right now. We will talk more next time d) I think that people just you’re just lazy and should earn money honestly 15) A nurse is obtaining the medical history of a client who has a new prescription for isosorbide monotitrate. Which of the following should the nurse identify as a contraindication to medication? a) Glaucoma b) Hypertension c) Polycythemia d) Migraine headaches 16) ? 17) The nurses is caring for a client recovering from an acute myocardial infarction. Which following intervention should the nurse include in the point of care? a) Draw a troponin level every four hours b) Performance EKG every 12 hours c) Plant oxygen tent fell over minutes via rebreather mask d) Obtain a cardiac rehabilitation consult 18) A Nurses caring for client who has breast cancer and has been covering receiving chemotherapy. Which of the following laboratory values should nurse report to provider? a) WBC 3,000/mm3 b) Hemoglobin 14 g/dl c) Platelet 250,000/mm3 d) aPTT 30 seconds 19) Home health nurse is carefully planned for Alzheimer’s disease. To the following action should the nurse include in the plan of care a) Place a daily calendar in the kitchen b) Replace button clothing with zippered items c) Replace the carpet with hardwood floors d) Create variation in daily routine 20) Nurse is performing change of shift assessments on 4 clients. Which of the following findings should the nurse report to provider first? a) The client was cystic fibrosis and has a thick productive clock and reports thirst b) Client who has gastroenteritis and is lethargic and confused c) The Client has diabetes mellitus has morning fasting Legal cost of 185 mg over deal d) The client was sick of signing it reports pain 15 minutes after receiving oral analgesic 21) A nurse is caring for a client was in the second trimester of pregnancy and asks how to treat constipation. Which of the following statements by the nurse is appropriate? a) Decrease taking vitamins and supplements to every other day 3 of 28 b) Eat 15 g of fiber per day c) Consume 48 ounces of water each day (need at least 64 oz) d) Drink hot water with lemon juice each morning when you wake up 22) ? 23) A nurse is caring for a client who is preparing his advance directives. Which is the following statements by the client indicates an understanding of advanced directives? select all that apply a) I can’t change my instructions once a minute b) My doctor will need to approve my advance directives c) I need an attorney to witness my signature on the advance directives d) I have the right to refuse treatment e) My health care proxy can make medical decisions for me 24) A nurse is caring for a client who is at 32 weeks gestation and has a history of cardiac disease. Which of the following positions should the nurse place the client to best promote optimal cardiac output? a) The chest b) Standing c) Supine d) Left lateral 25) A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an AP? a) Client who has chronic obstructive pulmonary disease and needs guidance on incentive spirometry b) Client who has awoken following a bronchoscopy and requests a drink c) Client who had a myocardial infarction 3 days ago reports chest discomfort d) Client who had a cerebrovascular accident two days ago and needs help toileting 26) Nurse providing discharge teaching to the client who has schizophrenia and is starting therapy with clozapine. Which of the following is the highest priority for the client to report to the provider? a) Constipation b) blurred vision c) Fever d) Dry Mouth 27) A nurse observes an AP providing care to a child who is in skeletal traction. Which of the following action requires intervention? a) Providing a high protein snack b) Assisting the child to reposition c) Placing weights as a child’s bed d) Massaging pressure points-causes skin breakdown 28) A nurse is planning to delegate to an AP the fasting blood glucose testing for a client who has diabetes mellitus. Which of the following action should the nurse take? a) Determine if the AP is qualified to perform the test. b) Help the AP performed the blood glucose test c) Assign the AP to ask the client is taking his diabetic medication today d) Have AP check the medical record for prior blood glucose test results 4 of 28 29) A nurse is assessing client brought to the hospital psychiatric emergency services by a law enforcement officer. The client has disorganized, incoherent speech with loose associations and religious content. You should recognize the signs and symptoms as being consistent with which of the following? a) Alzheimer’s disease b) Schizophrenia c) Substance intoxication d) Depression 30) A nurse is caring for a child who has infectious mononucleosis.. Which of the following findings are associated with this diagnosis? Select all that apply a) splenomegaly b) Koplik spots (this is associated with measles) c) Malaise d) Vertigo e) Sore throat 31) Nurse is performing dressing change for client was a sacral wound using negative pressure wound therapy. Which The following actions should the nurse take first? a) Apply skin preparation to wound edges. b) Normal saline c) Don sterile gloves d) Determine pain level 32) A nurses caring for client recovery from the bowel surgery who has nasogastric tube connected to low intermittent suction. Which the following assessment findings should indicate to the nurse that the NG tube may not be functioning properly? a) Drainage fluid is greenish-yellow b) aspirate pH of 3 c) Abdominal rigidity d) air bubbles noted in the NG tube 33) A nurse is preparing to administer TPN with added fat supplements to a client who has malnutrition. Which of the following action should the nurse take? a) Piggyback 0.9 sodium chloride with TPN solution b) Check for an allergy to eggs c) Discuss the TPS solution for 12 hours d) Monitor for hypoglycemia 34) A charge nurse is discussing the use of applying ice to a client’s injured knee with a newly licensed nurse. Which of the following should the nurse identify as a benefit? (A/C?) a) Systemic analgesic effect b) increase in your metabolism c) Decreased capillary permeability d) Vasodilation 35) Nurse is developing discharge care plans for client has osteoporosis. To prevent injury the nurse should instruct the client to a) Perform weight bearing exercises 5 of 28 b) Avoid crossing the legs beyond the midline c) Avoid sitting in one position for prolonged periods d) Split affected area 36) A nurse on acute med-surgical unit is performing assessments on a group of clients. Which is highest priority? a) The client has surgical hypoparathyroidism and positive Trousseau’s sign b) A client who was Clostridium difficile with acute diarrhea c) A client who is acute kidney injury and urine with a low specific gravity d) The client who has oral cancer and reports a sore on his gums 37) Nurses caring for a client was congestive heart failure. Which of the following prescriptions for the provider should the nurse anticipate? a) Call the provider to clients respiratory rate is less 18/min b) Give the client 500 mL IV bolus of 0.9 sodium chloride over 1 hr c) Give the client enalapril 2.5 mg PO twice daily d) Call the provider if the clients pulse rate is less than 80/min 38) A nurse is caring for a client who has a prescription for sertraline to treat depression. Which of the following statements by the client indicates an understanding of the medication treatment plan? a) I will be able starting this medication with feel better b) I can expect to urinate frequently while on this medication c) I understand I may experience difficulty sleeping on this medication d) I should decrease my sodium intake while on this medication 39) A nurse has been caring for a female client who has bruises on her arms that she explains are a result of physical abuse by her husband. The client states, “I don’t know how much longer I can take this, but I’m afraid he’ll really hurt me if I leave. “Which of the following is an appropriate nursing intervention?” a) Offer to speak to the client’s husband regarding his abuse behavior. b) Help the client to recognize the signs of escalation of abuse behavior c) Assist the client to identify personal behaviors that trigger abusive behavior d) Assist the client to Reports abusive behavior to the proper authority 40) A client was having suicidal thoughts tells the nurse “It just does not seem worth it anymore. Why not end my misery?” Which of the following responses for the nurses appropriate? a) Why do you think your life is not worth it anymore? b) Do you have a plan to end your life? c) I need to know what you mean my misery d) You can trust me and tell me what you’re thinking 41) A nurse is caring for a client who has schizophrenia. Which of the following assessment findings should the nurse expect? a) Decreased level consciousness b) Unable to identify common objects c) Poor problem solving ability d) Preoccupation was somatic disturbances 6 of 28 42) A nurse is caring for a client who has deep vein thrombosis of the left lower extremity. Which of the following action should nurse take? There are 3 tabs that contain separate categories of data. a) Position the client with the affected extremity lower than the heart b) Administration of acetaminophen c) Massage the affected extremity every 4 hrs. d) Withhold heparin IV infusion 43) Is caring for clients was a new prescription for enoxaparin for the prevention of DVT. Which of the following is an appropriate action by the nurse? a) Expel air bubble at the top of the prefilled syringe b) Massage the injection site to evenly distribute the medication c) Inject the medication the lateral abdominal wall d) Administer an NSAID for injection site discomfort 44) Nurses caring for four clients. Which of the following client data should the nurse report to the provider? a) A client who has a pleurisy and reports pain of 6 on a scale of 0 to 10 when coughing b) Client was a total of 110 mL of serosanguineous fluid from the Jackson Pratt drain within the first 24 hour following surgery c) Client who is 4 hrs postoperative and has a heart rate of 98 per minute d) The client was a prescription for chemotherapy and an absolute neutrophil count of 75/mm3 45) Nurses caring for client was in end-stage osteoporosis and is reporting severe pain. Clients respiratory rate is 14 per minute. Which of the following medications should the nurse expect to be the highest priority to administer to the client? a) Promethazine b) Hydromorphone c) Ketorolac d) Amitriptyline 46) A nurse is caring for a client who has DVT. Which of the following instructions the nurse include in the plan of care? a) Live with the clients fluid intake to 1500 mL per day b) Massage place affected extremity to relieve pain c) Apply cold packs of clients affected extremity d) Elevate the client’s affected extremity when in bed 47) A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client’s contractions are occurring every 45 seconds with a nine seconds duration in the fetal heart rate is 170 to 180/minute. Which of the following actions should nurse take? a) Discontinue oxytocin infusion b) Increased oxytocin infusion c) Decreased oxytocin infusion d) Maintain oxytocin infusion 48) A nurse is admitting a client who is in labor and at 38 wks of gestation to the maternal newborn unit. The client has a history of herpes simplex virus 2. Which of the following questions is most appropriate for the nurse to ask the client? a) Have your membranes ruptured? 7 of 28 b) How far apart are your contractions? c) Do you have any active lesions? d) Are you positive for beta strap? 49) Nurse is providing teaching for child prescribed ferrous sulfate. Which of the following instructions should the nurse include? a) Take with meals b) Take at bedtime c) Take with a glass of milk d) Take with a glass of orange juice 50) Four clients present to the emergency department. The nurse should plan to see which of the following clients first? a) A 6 year old client whose left shoulder is dislocated b) A 26 year old client for sickle cell disease and a severe joint pain c) A 76 year old client was confused, febrile and has foul smelling urine - uti d) A 50- year old client who has slurred speech, is disoriented, and reports a headache - stroke 51) A nurse is completing a dietary assessment for client who is Jewish and observes kosher dietary practices. Which of the following behaviors should the nurse expect to find? a) Leavened bread maybe eaten during Passover. b) Shellfish is commonly consumed in the diet. c) Meat and dairy products are eaten separately. d) Fasting from meat occurs during Hanukkah. 52) ? 53) A nurse is in an ER caring for client of multiple wounds due to a motor vehicle crash. Which of the following interventions are appropriate? Select all that apply a) Apply direct pressure to bleeding wounds b) Clean rest last rations and abrasions with hydrogen peroxide c) Cover wounds with a sterile dressing d) Administer 650 mg aspirin PO as needed for pain e) Determine date of last tetanus toxoid vaccination. 54) The nurses reviewing clients admission laboratory results. Which of the findings required further evaluation? a) Sodium 138 b) Creatinine 1.8 c) Hemoglobin 15 d) Potassium 4.2 55) A nurse is providing teaching for a client has a new prescription for methadone. Which of the phone following client statements indicates need for further teaching? a) I understand the methadone tends to slow my breathing b) I understand the methadone may cause me to have difficulty sleeping c) I will avoid alcohol while I’m taking this medication d) I’ll change positions gradually especially from lying down to standing 8 of 28 56) Which of the following client is appropriate for the nurse to refer to speech therapy for swallowing evaluation? a) Premature infant with a poor suck reflex and failure to thrive b) An older adults who has difficulty taking in fluids c) Adolescent who anorexia who is cachectic d) A middle aged adults was gastroesophageal reflux disease 57) A nurse is caring for a group of clients. Which of the following client should nurse assess first? a) A client whose benign prostatic hyperplasia and is unable to urinate b) The client was heart failure and report shortness of breath while ambulating c) A client who is open cholecystectomy and has green drainage from the T-tube d) A client whose abdominal pain and is vomiting coffee ground emesis 58) A nurse is taking a medication history from client was type II diabetes mellitus is scheduled for an arteriogram. Which of the following medications to the nurses instruct the client to discontinue 48 hrs prior to the procedure? a) Atorvastatin b) Digoxin c) Nifedipine d) Metformin 59) The nurses assessing client with posttraumatic stress disorder. Which of the following findings to the nurse expect to find? a) Dependence on family and friends b) Loss of interest in usual activities c) Ritualistic behavior d) Passive aggressive behavior 60) A nurse working in a long-term care facility is caring for an older adult client has dementia. The clients often agitated and frequently wanders the halls. Which of the following intervention should the nurse include in the plan of care? a) Give the client several choices when scheduling activities. b) Confront the client regarding unacceptable behavior c) Maintain Nutritional requirements by offering finger foods d) Stimulate the client by leaving the television on throughout the day 61) A nurse on a mental health unit receives report on four clients. Which of the following client should the nurse attend to first? a) A client who has begun to demonstrate catatonic behavior b) The client was compulsive behavior and is frequently drinking from the water fountain c) Client was having auditory hallucinations is becoming agitated d) A client was making sexual comments to clients of the opposite sex 62) A nurse is caring for the full term newborn immediately following birth. Which of the following actions should the nurse take first? a) Instill erythromycin ophthalmic ointment and the newborn’s eyes. b) Place identification bracelets on the newborn. c) Weigh the newborn. 9 of 28 d) Dry the newborn 63) A nurse receives report on a group of clients. Which of the following client should the nurse attend to first? a) A client who was admitted with asthma and has an SaO2 of 92% long receiving oxygen at 1 L per minute via nasal cannula b) A client was admitted with angina and reports left arm pain of 4 on a scale of 0 to 10 c) The client was type II diabetes mellitus in his blood with glucose level is at 80 mg/dL d) A client who had a gastric endoscopy and whose nasogastric tube is draining 30 mL per hour of green fluid 64) A client at 38 weeks of gestation enters the emergency department. The nurse should recognize that which of the following indicates that the client is in the latent phase of labor? a) The client reports the urge to push b) The cervix is dilated 2 cm c) Contractions are 2 to 3 minutes apart d) The client reports nausea and vomiting 65) The charge nurse for medical surgical units discovers client care assignments that should be reassigned. Which of the following delegated tasks should be reassigned? a) An AP is to calculate intake and output every two hours for client in acute renal failure. b) An AP is to collect vital signs every 30 minutes for client who had a cholecystectomy c) A licensed practical nurse is to check nasogastric tube placement for client list had a bowel resection. d) A licensed practical nurses to provide initial feeding for client who had a cerebrovascular accident. 66) A nurse caring for the client who has a cast due to a compound fracture to the right ankle. Which of the following findings requires immediate intervention? a) pruiritus under the cast b) Localized stabbing pain upon movement c) paresthesia of the distal extremity d) Edema present when leg is in the dependent position 67) The nurses providing care for preschoolers with acute gastroenteritis. Basing information below which of the following is an appropriate nursing action? Click on the links of this below for additional client information a) Offer the child a cup of chicken broth. b) Encourage the child’s intake of gelatin. c) Administer oral rehydration solutions. d) Institute a banana, Rice, applesauce, and toast diet. 68) The nurses caring for a client whose taking allopurinol. The nurse should monitor which of the following laboratory findings to determine the effectiveness of the medication? a) Serum chloride b) Uric acid level c) Serum albumin d) Magnesium level 69) A nurse is caring for a client on the cardiac care unit who is hemodynamically unstable. Which of the following dysrhythmias should the nurse plan for cardioversion? 10 of 28 a) Ventricular asystole b) Third-degree AV block c) Atrial fibrillation d) Ventricular fibrillation 70) Nurse managers preparing an educational program on infection control measures. Which of the following should the nurse include when discussing contact precautions? a) Scarlet fever b) Herpes simplex c) Varicella d) Streptococcal pharyngitis 71) A nurse assesses an older adult client with the decrease caloric intake and weight loss. Which of the following findings should the nurse report to the provider immediately? a) The clinic experiences coughing and wheezing after eating. b) The client reports abdominal pain at a five on a scale of 0 to 10. c) The client experience is a drop in oxygen saturation to 91% while eating. d) The client reports a burning sensation in epigastric area. 72) A nurse and an assistive personnel are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate an AP? a) Applying condom catheter for client for spinal cord injury b) Administrative oral fluids to client was dysphasia c) Documenting the report of pain from client who is postoperative d) Reviewing active range of motion exercises with a client who is had a stroke 73) A nurse from the state health department this is instructing a group nurses regarding reportable infections. Which of the following infections should the nurse report to the CDC? a) Candida albicans b) Herpes simplex virus 2 c) staphylococcus aureus d) Lyme disease 74) The nurse is assessing an adolescent client for sickle cell anemia. Which of the following is a priority finding by the nurse? a) A pain score 7 on a scale of 0 to 10 b) Shortness of breath c) New onset of a new enuresis d) Priapism 75) Nurses caring for a client whose 1 day postop following a Hypophysectomy for the removal of the pituitary tumor. Which of the following findings requires further assessment by nurse? a) Glascow scale score a 15 b) Blood drainage on initial dressing measuring 3 cm c) Report of dry mouth d) Urinary output greater than fluid intake 11 of 28 76) A client with the left leg cast is using crutches for ambulation. The nurse recognizes client needs further instruction of the client a) Flexes elbows at 30 degrees when using the handgrips b) Maintains 3 to 4 finger width between the crutch pad and axilla c) Places the crutches 6 inches in front and side of each foot when standing. d) Pushes up from a chair with crutches on the unaffected side. 77) A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take? a) Use a designated stethoscope when caring for the toddler. b) Wear an N95 respiratory mask while caring for the toddler. c) Remove the disposable gown after leaving the toddler’s room d) Place the toddler in a room with negative air pressure. 78) A nurse is admitting to a client to emergency department and initiates continuous cardiac monitoring. Which of the following ECG with strips indicates sinus tachycardia? b) 79) A nurse is planning care for client to prevent complications of immobility. With the following actions should the nurse including the plan of care? a) Massage lower extremities daily to prevent DVT b) Limit intake of Food high in calcium to prevent renal calculi. c) Encourage client to lie supine prevent constipation. d) Remove anti embolism stockings for 3 hours each day to decreased skin breakdown. 80) A nurse discovers that the wrong dosage of medication was given to client. When determining what action to take your should recognize that which of the following ethical principles should be applied? a) Utility b) Paternalism c) Veracity d) Fidelity 81) ? 82) A nurse is review in the prescription for doxazosin with a client. Which of the following should be included in the teaching? a) Decrease caloric intake to reduce weight gain. b) Increased dietary fiber to prevent constipation. c) Rise slowly when sitting up from bed. 12 of 28 d) Take this medication each morning. 83) Addresses planning to provide teaching to young adult client who is insomnia. Which of the following should the nurse include in the teaching? a) Exercising an hour before bedtime b) Take a short nap today c) Keep bedroom cool at night d) Consume a high carbohydrate snack at bedtime. 84) A nurse is caring for client who has a stool culture that is positive for Clostridium difficile. Which of the following infection control precautions is appropriate? a) Wear a face shield prior into entering the room. b) Place the client private room. c) Place the client in a negative pressure room. d) Use alcohol based hand rub following client care. 85) A nurse is planning care for a child who has increased intracranial pressure with a decreased level of consciousness. Which of the following intervention should the nurse including the plan of care? a) Perform active range of motion exercises. b) Perform neurological checks every 4 hours. c) Suction the airway frequently. d) Maintain the head at a midline position. 86) The nurse is assessing a client is receiving radiation therapy. Which of the following findings should the nurse expect? a) White blood cell count at 12,500 mm3 b) Excessive salivation c) +3 pitting edema d) Platelets 95,000 mm3 87) A nurse is caring for a client who has preeclampsia and is experiencing postpartum hemorrhage. The nurse should identify that which of the following medications is contraindicated? a) Methylergonovine. b) Misoprostol c) Dinoprostone d) Oxytocin 88) A nurse is caring for client was GERD. Which of the following assessment findings the nurse expect to find? a) Shortness of breath b) Rebound tenderness c) Atypical chest pain d) Vomiting blood 89) A nurse is caring for a newborn who is under phototherapy lights. Which of the following is an appropriate nursing action? a) Ensure eye shield is covering the eyes. b) Apply lotion to expose skin. 13 of 28 c) Offer glucose water between feedings. d) Discontinue breast-feeding during treatment. 90) This is assessing clients as had a long arm cast. Which of the following findings of the dress moderate and when assessing for acute compartment syndrome? a) Shortness of breath b) Petechiae c) Change in mental status d) Edema 91) I Just came from client is receiving IV moderate (Conscious) sedation with midazolam. The client has a respiratory rate of 9/min and is not responding to commands. Which of the following is an appropriate action by the nurse? a) Placed the client in a prone proposition. b) Implement Positive pressure ventilation. c) Perform nasopharyngeal suctioning. d) administer flumazenil 92) A nurses in a hospital cafeteria overhears two assistive personnel (AP) discussing a client. They are using the clients name and discussing details of his diagnosis. Which of following actions should the nurse take first? a) Report the AP’s behavior to the supervisor. b) Completed instant report regarding the Aps conversation. c) Provide the AP with written documentation regarding client confidentiality d) Tell the AP to discontinue their conversation 93) A community health nurse is teaching a group of adults about the importance of health screenings. The nurse should include African American males almost twice as likely as caucasian males to experience which of the following? a) testicular Cancer b) Obesity c) Stroke d) Melanoma 94) A nurse is caring for a client who sprained his left ankle 12 hrs ago . Which of the following prescription is given by the provider should the nurse clarify? a) Over the fact that extremities and two pillows. b) Apply heat to affect extremity for 45 minutes on the 45 is off. c) wrap the affected extremity with a compression dressing. d) Assess the affected extremity for sensation movement impulse every four hours 95) A nurse is providing dietary teachings for client who has hepatic encephalopathy. Which the following food selections indicates that client understands teaching? a) A sandwich and milkshake b) Rice with black beans c) Cottage cheese and tuna lettuce d) Three egg omelette with low-sodium ham 14 of 28 96) A nurse is planning care for client sealed radiation implant and is to remain in the hospital for 1 week. Which of the following should the nurse include in the plan of care? a) Remove dirty linens from the room after double bagging. b) Wear a dosimeter film badge while in the client’s room c) Limit each of the clients is yours to one hour per day. d) Ensure family members remain at least 3 feet from the client. 97) A nurses for Caring for four clients. Which of the following client should the nurse care for first? a) A client to receive a chemotherapy treatment or first national b) A client who has an appendectomy to these don’t has diminished all sounds c) A client is hypothyroidism and his stuporous d) A client who is a burn requiring a sterile dressing change 98) The nurses planning care for newly admitted adolescent who has bacterial meningitis. Which the following instructions is appropriate for the nurse to include in the plan of care? a) Initiate droplet precautions for the client b) Assisted client to supine position c) Performing Glasgow coma scale every 24 hrs d) Recommend prophylactic acyclovir there for the clients family. 99) Nurse is giving discharge instructions to client has new ileostomy. The nurse should recognize that the teaching has been effective when the client states. a) I want sure that my medications are enteric coated b) My stoma will drain liquid fluid continuously c) I will change my pump system every two weeks d) My stoma size will stay the same even after healed 100) A nurse in a provider’s office is interviewing a client who is requesting an oral contraceptive. Which of the following findings in the client’s history is a contraindication to use in combination oral contraceptives? a) thyroid disease b) Allergy to penicillin c) impaired liver function d) abnormal blood glucose 101) The nurses providing teaching to a client who has mild persistent asthma has been prescribed montelukast. Which of the following statements to the nursing put in teaching? a) This medication can be used to help you when have an acute asthma attack b) This medication should be taken before exercise and physical activity c) This medication can be taken for 10 days and then gradually discontinued d) This medication helps decrease swelling and mucus production 102) I nurse on the medical surgical unit is receiving reports on four clients. Which of the following client should the nurse assess first? a) A client who is receiving warfarin and has and INR of 3.3 b) A client who has an acute kidney injury, a creatinine of 4 mg/dL, and a BUN 52 mg/dL c) A client who had a NG tube inserted 6 hr ago and has abdominal distention 15 of 28 d) A client who is 4 hr postoperative following a thyroidectomy and reports fullness in the back of the throat 103) A nurse is assessing a client who has pericarditis. Which of the following findings is priority a) Paradoxical pulse pg. 389 under complications b) dependent edema c) Pericardial friction rub d) Substernal chest pain 104) A charge nurse is providing teaching to a new licensed nurse on how to cleanup surfaces contaminated with blood. Which of the following agents said the nurse include in the teaching? a) Hydrogen peroxide b) Chlorhexidine c) Isopropyl alcohol d) Chlorine bleach 105) *A nurse is preparing to feed a newly admitted patient with dysphagia. Which of the following actions in response take? a) instruct the client to lift her chin when swallowing b) discourage the client from coughing during feedings c) Sit at or below the clients eye level during feedings. d) Talk with the client during her feeding. 106) A nurses caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel telling the client. “If you don't eat, I’ll put restraints on your wrists and feed you.” The nurse should intervene and explain to the AP that this statement constitutes which of the following torts? a) Assault b) Battery c) Malpractice d) Negligence 107) A charge nurse is evaluating the time management skills for new licensed nurse. The charge nurse should intervene when a newly licensed nurse does which of the following? a) Re-Evaluate priorities halfway through the shift b) Delegate changing sterile dressing for licensed practical nurse c) Groups activities for the Same client d) Works on several tasks simultaneously 108) A nurse is monitoring the client during an IV urography procedure. Which of the following client reports is the priority finding? a) Feeling flushed and warm b) Abdominal fullness c) Swollen lips d) Metallic taste in mouth 109) A nurse is planning to delegate client assignments to the assistive personnel. which of the following task is appropriate for the nurse to delegate? a) Just the flow rate of the clients oxygen tank 16 of 28 b) Collecting urine sample c) Measuring the clients pain level d) Monitoring blood glucose levels 110) A nurse is assessing a client wasn’t following vital signs: Oral temperature of 37.2°C (99 F). Apical pulse rate of 80/min, radial pulse rate 62/min, respiratory rate of 16/min, and blood pressure of 132/40 mm Hg. What is the clients pulse pressure? a) Systolic presssure subtracted by diastolic pressure (132 - 40) = 92 111) A nurse if caring for a group of clients in a medical surgical unit. Which of the following situations requires completion of an incident report? a) A client who is absent gag reflex following a bronchoscopy b) A client whose IV pump has malfunctioned c) A client who requires insertion of NG tube due to a bowel obstruction d) A client who is absent bell sounds following a gastrectomy 112) A nurse is caring for a client who has diabetes insipidus and is receiving desmopressin. Which of the following should nurse monitor? a) Fasting blood glucose b) Carbohydrate intake c) Hematocrit d) Weight 113) The nurses providing discharge instructions about engorgement for client has decided not to breastfeed. Which of the following statements by the client indicates a need for further instruction by the nurse? a) I can wear support bra b) I will play cold compression my breasts c) I will manually express breastmilk d) I can take a mild analgesic 114) A nurses caring for client in preterm labor who is receiving magnesium sulfate by continuous IV infusion. Which of the following client findings indicates medication toxicity? a) Blood glucose of 150 mg/dL b) Urine output of 20 mL per hour c) Systolic blood pressure at 140 mm Hg d) BUN 20 mg/dL 115) The nurse is completing an assessment for newborn who is 2 hrs old. Which of the following findings are indicative of cold stress? a) Respiratory rate of 60 per minute b) Jitteriness of the hands c) Diaphoretic d) Bounding peripheral pulses in all extremities 116. A nurse is planning care for four clients. Which of the following clients is the highest priority? a. A client who is dry, black eschar on the heel b. A client who is wearing an arm cast and reports numb fingers 17 of 28 c. The client was reddened skin area with blanching around the coccyx d. The client who has frequent incontinence 117. A nurse is caring for a male adolescent client who has heart failure. Based on the client’s chart finds. Which of the following actions should the nurse plan to take? a. Withholds spiranolactone b. Administer ferrous sulfate c. Administer furosemide d. Withhold digoxin (0.8-2.0) 118. The nurses assessing a client plus blood glucose level of 250 mg/dl. Which of the following clinical manifestations are associated with this finding? a. Confusion (hypoglycemia) b. Thirst c. Diaphoresis (hypoglycemia) d. Shakiness (hypoglycemia) 119. A nurse is assessing for allergies before administering Propofol to a client placed on the mechanical ventilator. Which of the following allergies is a contraindication to the medication? a. Eggs b. Milk c. Shrimp d. Peanuts 120. A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client to interpret the following statement, “When the cat’s away, the mice will play”. The client response was, “The mice come out when the cat is not around”. The nurse should document this finding which of the following in the client’s chart? a. Echolalia b. Associative looseness c. Neologisms d. Concrete thinking 121. A nurse caring for a client who is receiving total parental nutrition. Which of the following assessment findings required immediate intervention by the nurse? a. prealbumin level of 20 mg/dL b. Weight increase of two kg/day c. Temperature of 37.6°C d. Blood glucose level of 120 mg/dL 122. A nurse in the telemetry unit is receiving the laboratory findings for adult male client who’s been treated for myocardial function. The following is an expected finding for the client? a. Troponin 1 (TNI) 8 ng/ml b. Brain natriuretic peptide (BNP) 10 ng/L c. Alanine aminotransferase (ALT 45 unit/L d. High density lipoprotein (HDL) 75 mg/dl 18 of 28 123. A nurse is reviewing the results of an ABG performed on a client with chronic emphysema. Which of the following results suggests the need for further treatment? a. paO2 level of 89 mm Hg b. PaCO2 level of 55 mm Hg c. HCO2 level of 25 mEq/L d. pH level of 7.37 124. A nurse is teaching a client about nutritional intake. The nurse should include which of the following in the teaching? a. "Carbohydrates should be at least 45% of your caloric intake." b. "Protein should be at least 55% of your calorie intake." c. "Carbohydrates should be at least 30% of your caloric intake." d. "Protein should be at least 60% of your caloric intake." 125. A nurse is caring for a client who has a prescription for vancomycin 1 g IV every 12 hr. The client is scheduled to have the morning dose at 0700. The nurse should schedule the trough level to be drawn at which of the following times? a. 2100 b. 0900 c. 1300 d. 1800 126. A nurse is planning an education session for a client who has type 1 diabetes mellitus. Which of the following should the nurse plan to include when teaching the client to monitor for hypoglycemia? a. diaphoresis b. polyuria c. abdominal pain d. thirst 127. A nurse in an urgent-care clinic is collecting admission history from a client who is 16 weeks of gestation and has bacterial vaginosis. The nurse should recognize that which of the following clinical findings are associated with this infection? a. Frequency and dysuria b. Profuse milky white discharge c. Hematuria d. Low grade fever 128. A nurse is planning care for a client who has a new diagnosis of dysphagia. Which of the following foods should be included when initiating feeding? a. beef broth b. oatmeal c. apple juice d. toast 129. A nurse receives a change-of-shift report. Which of the following clients should the nurse attend to first? a. A client who reports tingling in the fingers following a thyroidectorny b. A client who has dark, foul-smelling urine with a urine output of 320 mL in the last 8 hr 19 of 28 c. A client who is in a long leg cast and reports cool feet bilaterally d. A client who has a productive cough and an oral temperature of 36° C (96.80 F) 130. A nurse is caring for a client who has lactose intolerance and has eliminated dairy products from his diet. The nurse should instruct the client to increase consumption of which of the following foods? a. spinach b. peanut butter c. ground beef d. carrots 131. A client who is 8 hr postpartum asks the nurse if she will need to receive Rh immune globulin. The client is gravida 2, para 2, and her blood type is AB negative. The newborns blood type is B positive. Which of the following statements is appropriate? a. You only need to receive Rh immune globulin if you have a positive blood type." b. You should receive Rh immune globulin within 72 hours of delivery." c. "Both you and your baby should receive Rh immune globulin at your -week appointment." d. "immune globulin is not necessary since this is your second pregnancy." 132. A nurse is caring for the mother of an adolescent who was killed in a motor-vehicle crash after a school event. The mother states, I never should have let him take the car. Its all my fault!" Which of the following responses by the nurse is appropriate? a. You had no way of knowing this would happen." b. Most parents blame themselves when losing a child." c. Tell me why you feel this is your fault." d. You appear to be feeling overwhelmed" 133. A nurse is educating a client about caloric intake and weight reduction. Which of the following client statements indicates an understanding of the teaching? a. “If I eat 500 fewer calories per day, I should lose 1 pound per week.” b. “ If I eat 500 fewer calories per day, I should lose 1 pound per week." c. "If I eat 450 fewer calories per day, I should lose 2 pounds per week." d. "If I eat 250 fewer calories per day, I should lose 2 pounds per week." e. "If I eat 300 fewer calories per day, I should lose 1 pound per week.” 134. A nurses is teaching post-operative care with the parents of a toddler following a cleft palate repair. Which of the following should be included in the teaching? a. Provide an orthodontic pacifier for comfort. b. Offer fluids by using a straw. c. Cleanse suture line with a cotton tip swab. d. Remove elbow splints periodically to perform range of motion. 135. A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel? a. Perform chest compressions during cardiac resuscitation. b. Perform a dressing change for a new amputee. c. Assess effectiveness of antiemetic medication. d. Provide discharge instructions 20 of 28 136. A nurse in an emergency department is serving on a committee that is reviewing the facility protocol for disaster readiness. The nurse should recommend that the protocol include which of the following as a clinical manifestation of smallpox? a. Bloody diarrhea b. Ptosis of the eyelids c. Descending paralysis d. Rash in the mouth 137. A nurse is preparing to perform closed intermittent bladder irrigation for a client following a transurethral resection of the prostate (TURP). Which of the following actions is appropriate by the nurse? a. Aspirate the irrigation solution from the bladder. b. Insert the tip of the irrigation syringe into the catheter opening. c. Apply sterile gloves. 1296 in med surgical book d. open the flow clamp to the irrigating fluid infusion tubing. 138. A nurse is caring for a client who has been taking haloperidol for several years. Which of the following assessment findings should the nurse recognize as a long-term side effect of this medication? a. Lipsmacking b. Agranulocytosis c. Clang association d. Alopecia 139. A nurse is planning care for a client who has Alzheimers disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care? a. Place the client in seclusion when she is confused. b. Request a prescription for PRN restraints when the client is wandering. c. Dim the lighting in the clients room. d. Leave one side rail up on the clients bed. 140. A nurse is reviewing the laboratory data of a client who has diabetes mellitus. Which of the following laboratory tests is an indicator of long-term disease management? a. Postorandial blood glucose b. Glycosylated hemoglobin - Ha1c c. Glucose tolerance test d. Fasting blood glucose 141. A nurse on a pediatric care unit is delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel? a. Initiate a dietary consult for a toddler. b. Administer a glycerin suppository to a preschool-age child. c. Evaluate gastric residual following intermittent feeding of an adolescent. d. Transport a school-age child to x-ray. 142. A nurse is caring for a client who has been taking propranolol. Which of the following findings indicates a need to withhold the medication? a. sodium 130 mEq/L 21 of 28 b. Blood pressure 156/90 mm Hg c. Potassium 5.2 mEq/L d. Pulse 54/min 143. A nurse working in a mental health facility observes a client who has bipolar disorder walk over to a table occupied by other clients and knock their game off the table. Which of the following is an appropriate response by the nurse? a. Apologize to the others for your behavior." b. I am disappointed that you continue to act out when you are angry." c. Come outside with me for a walk." d. If you dont calm down, you will have to go into seclusion." 144. A nurse is caring for a client who has human immunodeficiency virus (HIV) with neutropenia. Which of the following precautions should the nurse take while caring for this client a. Wear an N95 respirator while caring for the client. b. Use a dedicated stethoscope for the client. c. Insert an indwelling urinary catheter to monitor urinary output. d. Monitor the client’s vital signs every 8 hr. 145. A nurse is checking laboratory results for a client. Which of the following laboratory findings indicates hypervolemia? a. serum sodium 138 mEq/L b. Urine specific gravity 1.001 c. serum calcium 10 mg/dL d. Urine pH 6 146. A nurse is caring for a group of clients in a long-term care facility. Which of the following situations should the nurse recognize as a safety hazard? a. A client’s wrist restraints tied to the bed rails b. A clients bedside table placed across the foot of the bed c. A meal tray left at the bedside from breakfast d. A call light extension cord pinned to the bedspread 147. A nurse is caring for a client in a mental health facility. The clients daughter is crying and tells the nurse that she feels guilty for leaving her father in the hospital. Which of the following is an appropriate response? a. I’d like to know more about what’s bothering you." b. "Why are you feeling this way" c. "You did the right thing by bringing him here." d. "I’m sure your father doesn’t blame you." 148. A nurse is planning care for a client following gastric bypass surgery. The nurse should include which of the following dietary instructions when preparing the client for discharge? a. start each meal with a protein source. b. Consume at least 25 g of fiber daily. c. Check your blood glucose level before each meal. d. Limit your meals to three times per day. 22 of 28 149. 149 A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse? a. Tidaling with spontaneous respirations b. Drainage collection chamber is 1/3 full c. 1 cm of water present in the water seal chamber d. Suction chamber pressure of -20 cm H20 150. A provider has written a do not resuscitate order for a client who is comatose and does not have advance directives. A member of the clients family says to the nurse, “I wonder when the doctor will tell us what’s going on" Which of the following actions should the nurse take first a. Request that the provider provide more information to the family. b. Refer the family to a support group for grief counseling. c. Offer to answer questions that family members have. d. Ask the family what the provider has discussed with them. 151. A nurse is performing a skin assessment on a client who has risk factors for development of skin cancer. The nurse should understand that a suspicious lesion is a. scaly and red b. asymmetric, with variegated coloring c. firm and rubbery d. brown with a wart-like texture 152. A nurse is interviewing an older adult client about the physiological changes he has been experiencing. Which of the following changes should the nurse recognize is normally associated with the aging process? a. Decreased sense of taste b. Decreased blood pressure c. Increased gastric secretions d. Increased accommodation to near vision 153. A nurse in an intensive care unit is planning care for a client who has alcohol withdrawal syndrome. Which of the following should the nurse include in the plan of care? a. Administer disulfiram. b. Provide frequent orientation to time and place. c. Engage the client in group therapy. d. Perform gastric lavage. 154. A nurse is assessing a client’s cardiovascular system. Identify where the nurse should place the diaphragm of the stethoscope to best hear the closing of the aortic heart valve. (Selectable areas or Hot Spots" can be found by moving your cursor over the artwork until the cursor changes appearance, usually into a hand. Click only on the Hot Spot that corresponds to your answer.) 23 of 28 a. Top left site 155. A nurse manager is planning an audit to measure the quality of care on the unit. Which of the following is the most appropriate source for the nurse to consult? a. Nursing manager colleagues b. Evidence-based practice data c. Hospital administrators d. Protocols in other hospitals 156. A nurse is caring for a client who had gastric bypass surgery 1 week ago and has signs of early dumping syndrome. Which of the following findings should the nurse expect? (Select all that apply) a. Facial flushing b. Syncope c. Diaphoresis d. Vertigo e. Bradycardia 157. A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect? a. feelings of dread b. rapid speech c. purposeless activity d. heightened perceptual field 158. A nurse is delegating tasks to an assistive personnel. Which of the following instructions demonstrates appropriate communication of the task? a. "Take a blood glucose fingerstick on the client in room 102 before breakfast and then place the glucometer into the docking station." b. "Obtain a blood pressure reading from the client in room 116 after lunch and report a systolic level less than 90." c. "Assist the client in room 110 to ambulate once around the unit and stop if she gets short of breath." d. "Turn the client in room 126 to prevent pressure areas on his hip bones." 159. A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood pressure. The nurse should recognize that these findings are potential manifestations of which of the following? a. Nicotine withdrawal b. Heroin intoxication c. Alcohol withdrawal 24 of 28 d. Amphetamine intoxication 160. A nurse is assessing an older adult client who had a stroke. Which of the following findings should the nurse recognize as an indication of dysphagia? a. Abnormal movements of the mouth b. Inability to stand without assistance c. Paralysis of the right arm d. Loss of appetite 161. *A nurse is providing preoperative teaching to a client who will use PCA morphine sulfate following surgery. Which of the following information should the nurse include? a. The client should notify the nurse when administering a dose of the medication. b. The client can administer a dose of medication every 6 to 8 min. c. The client should be cautious to avoid overmedication (OD). d. Family members can administer a dose the client. 162. A nurse is assisting the provider with a paracentesis for a client who has ascites. Following collection of the specimen, which of the following actions should the nurse take next a. Document the procedure. b. Measure the drainage. c. Record the color of the drainage. d. Label the specimen. 163. A nurse is caring for a client in an inpatient facility who tells the nurse that she is leaving because the facility policy prohibits smoking inside. Which of the following actions should the nurse take? a. Notify security to monitor the facility exits. b. Place the client in seclusion. c. Inform the client of the risks involved if she leaves. d. Call the provider for a discharge prescription. 164. A nurse is preparing to administer a measles, mumps, rubella (MMR) immunization to a child. Which of the following is a contraindication for administration? a. Recent blood transfusion b. Allergy to penicillin c. Minor acute illness d. Low-grade fever 165. A nurse is preparing to administer 2.5 mL of medication intramuscularly to an adult client. Which of the following is the safest site for the nurse to use? a. Ventrogluteal b. Dorsogluteal c. Vastus lateralis d. Rectus femoris 166. A nurse is teaching a female client how to reduce the risk of urinary tract infections (UTIs). Which of the following should the nurse include as a risk factor for developing a UTI? a. Wearing underwear with a cotton crotch b. Wiping from front to back 25 of 28 c. Using perfumed toilet paper d. Urinating immediately after intercourse 167. A nurse is providing discharge instructions for a client who has a new prescription for furosemide. Which of the following client statements indicates a need for further teaching? a. "I will take my morning pills with food or milk." b. "I will weigh myself every day." c. "I will notify the nurse if I have muscle cramps." d. "I will limit my intake of fish." 168. A nurse is caring for a client who has a prescription for atorvastatin. Which of the following client conditions is a contraindication to this medication? a. hepatits C b. peptic ulcer disease c. bronchitis d. chrohn’s disease 169. A nurse is planning care for an adolescent who has chronic renal failure. Which of the following actions should the nurse include in the plan of care? a. Encourage a diet high in calcium. b. Provide a diet high in potassium. c. Ensure increased fluid intake. d. Restrict protein intake to the RDA. 170. A nurse is assessing a client 1 hr following birth and notes that her uterus is boggy and located 2 cm above the umbilicus. Which of the following actions should the nurse take first? a. Take vital signs. b. Assess lochia. c. Massage the fundus. d. Give oxytocin IV bolus. 171. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following interventions should the nurse perform a. Give 100 mL of water with every feeding. b. Obtain gastric residuals every 24 hr. c. Position the head of bed at 30 degrees during feeding. d. Mix the clients medications with the tube feedings. 172. A nurse is caring for a 7 month-old infant who is being treated for severe dehydration. Which of the following assessment findings indicates treatment has been effective? a. Skin turgor displays tenting b. Flat anterior fontanel c. Cool, mottled skin d. hyperpnea 173. A nurse is providing teaching to a client who has esophageal cancer and is scheduled to start radiation therapy. Which of the following should the nurse include in the teaching? a. Remove dye markings after each radiation treatment. 26 of 28 b. Apply a warm compress to the irradiated site. c. Wear clothing over the area of radiation treatment. d. Use a washcloth to bathe the treatment area. 174. A nurse in a provider's office is providing education to a client who is 16 weeks of gestation and has a new prescription for ferrous sulfate. Which of the following instructions should the nurse provide a. Avoid strawberries, citrus fruit, and melon to ensure that your iron medication is effective." b. "Take your iron medication with fluids other than coffee or tea." c. "It is important to take your iron medication on a full stomach." d. "If you miss a dose one day, take two doses the next day." 175. 175 A nurse receives a change-of-shift report on four clients. Based on the shift report information, which of the following clients should the nurse plan to assess a. A client who had a hip arthroplasty reports pain and erythema in his calf b. A client who has anorexia and peripheral edema c. A client who has Addison's disease with a blood glucose level of 75 mg/dL d. A client who had a barium enema 2 days ago and reports constipation 176. A nurse administers a dose of metoclopramide to a client prior to chemotherapy treatment. Which of the following medications should the nurse administer? a. Albuterol sulfate b. Hydromorphone c. Diphenhydramine d. Amitriptyline 177. A client who does not speak English arrives at the emergency department accompanied by a child. Which of the following actions should the nurse take? 178. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displays toxicity. Which of the following actions should the nurse take? a. Position the client supine. b. Prepare an IV bolus of dextrose 5% in water c. Administer calcium gluconate IV. d. Administer methylergonovine IM. 179. A nurse is using Naegeles rule to calculate the expected delivery date for a newly pregnant primigravida. The first day of the clients last period was October. What is the expected delivery date? (Provide the date using four numerals, the first two for the month and the second two for the day. For example, January 2 0102) a. 0711 (July 7, 2011) Formula: +1 year, -3 months, +7 days 27 of 28 180. A nurse on a medical-surgical unit is receiving report on four clients. Which of the following clients should the nurse assess first? a. A client who is scheduled for chemotherapy and has a hemoglobin of 9 b. A client who is 24 hr postoperative following a transurethral resection of the prostate (TURP) and has small blood clots in the urinary catheter c. A client who is receiving a blood transfusion and reports low-back pain d. A client who has a new colostomy with a reddish-pink stoma 28 of 28