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ATI PN Comprehensive PredictorForm B| Questions and Answers |

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• A nurse in a long-term care facility is assisting with an in-

service for newly hired assistive personnel about legal issues within the
facility. Whichof the following should the nurse include as an example of
assault?
ANS: Informing a client the nurse is going to administer an injection
even though the client refuses
.
• A nurse is contributing to the plan ofIcare for a care for a client who has
chest tube connected to a closed drainage system. Which ofIthe following
actions should the nurse i nclude in the plan of care?
ANS: Maintain the drainage system below the level ofIthe client's chest.

• A nurse in an acute mental health facility is caring for a client who has
borderline personality disorder and reports. "I am going to kill my
girlfriend when I get out ofIhere." Which ofIthe following actions should
the nurse take?
ANS: Notify the client's care team of the threats against the partner

• A nurse is admitting a client who is at high risk for suicide. Which ofIthe
following actions is the nurse's priority?
ANS: Search the client's personal belongings
• A nurse is caring for a client who is 1 day postoperative and is unable to
ambulate. W hich ofIthe following actions should the nurse take to
promote the client's venous return?
ANS: Maintain the sequential compression device.

• A nurse on an acute care unity is collecting data from a school-

age Child who has cystic fibrosis. Which ofIthe following findings is the
priority for the nurse?
ANS: Reports lack ofIappetite

• a nurse working in a provider's ofollowingice receives a phone call from


the parent ofIa school-
age child who has varicella. The parent asked the nurse when the child can
return to school. Which ofIthe following responses should the nurse make?
ANS: "When the lesions have scabbed over."
• A nurse in a pediatric clinic is collecting the data from a school-

age child whose injuries are inconsistent with the parent's stated cause.
Which ofIthe following actions should the nurse take?
ANS: Report the suspected abuse to a appropriate agency.

• A nurse is collecting data from a middle adult female client who is


taking melatonin.Which ofIthe following responses to the med should
the nurse expect?
ANS: Improved sleep

• A nurse on a pediatric unit is collecting data from four newly admitted


clients. Which ofIthe following clients should the nurse identify as being
at risk for urinary retention?ANS: A school-
age child who has allergic rhinitis and is taking diphenhydramine.

• A nurse is preparing to administer purified protein derivative (PPD) to a


client who ha s suspected TB. Which ofIthe following actions should the
nurse plan to take?
ANS: Ensure the injection produces a wheal on the skin

• A client who is diagnosed with Parkinson's disease verbalizes frustration


due to increas e difollowingiculty with ambulation. Which ofIthe following
responses should the nurs e take?
ANS: Perform active ROM with your arms and legs two times a day.

• a Nurse is collecting data from a client who has multiple fractures


following a motor-vehicle crash. For which ofIthe following client
statements
ANS: "I am so frustrated. I cannot even open my milk carton for
breakfast."
• A nurse is collecting data from who is severe pain. Which ofIthe following
questions should the nurse ask first?
ANS: "Where is your pain located?"

• A nurse is reinforcing teaching about ways to reduce solid fat


consumption with a clie nt who has an elevate cholesterol level. which
ofIthe following strategies should the nurse include in the teaching?
ANS: purchase beef that is a loin cut.

• A nurse is reinforcing teaching with a client who has a new prescription


for prednisonefor the treatment ofIAddison's disease. which of the
following instructions should the nurse include in the teaching?
ANS: You will need to schedule a bone density test.

• A nurse is collecting data from a client who has type 2 diabetes mellitus
and is concer ned about weight gain during pregnancy. Which ofIthe
following responses should the nurse make?
ANS: You weight gain should be the same as for someone without
diabetes.

• A nurse is reinforcing teaching with the parent ofIa preschooler who has
lactose intoler ance. Which ofIthe following statements by the parent
indicates an understanding ofIth e teaching?
ANS: I should ofollowinger my child yogurt that has a probiotic as a
snack.

• A parent brings her adolescent son to an urgent care center and states.
"He is high on something and needs help" The client is exhibiting
agitation and paranoia and reports visual hallucinations. The nurse should
suspect intoxication with which ofIthe following substances?
ANS: Methamphetamines

• A nurse notices an assistive personnel taking a nap in the break room


during he meal t ime. The AP appears drowsy while performing routine
tasks. Which ofIthe following a ctions should the nurse take?
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ANS: Report the observations about the ap to the unit's nurse manager.

• A nurse is reinforcing teaching with a client who has a fluid volume deficit
about selec ting foods that have a high water content. The nurse should
include that which ofIthe f ollowing raw foods contains the highest
amount ofIwaterIper 1 cup serving?
ANS: Cherry tomatoes

• The nurse is position a client who is scheduled for a lumbar puncture.


The nurse should assist the client into which of the following positions?
ANS: Lateral Recumbent.

• A nurse is talking with a client whose son died in a motor-

vehicle crash 2 weeks ago. The client states "I really thought I;d be back to
my usual r outines by now, but I can't think ofIanything else except my son
is gone" Which ofIthe following responses should the nurse make?
ANS: Grieving for your son is hard work. It will take as much time as
you needto come to terms with your loss.

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• A nurse is reviewing the laboratory results for a client who is at 29 weeks
gestation. For which of the following results should the nurse notify the
provider?
ANS: Platelet count 95,000 mm3

• A nurse is performing a dressing change for a client who had abdominal


surgery 5 day s ago. The nurse notes organs protruding from the incision.
Which ofIthe following act ions should the nurse take?
ANS: Cover the exposed area with sterile, saline-soaked dressings.

• A nurse is speaking with the adult daughter ofIa client who has
Alzheimer's disease. T he daughter states, "I love my dad, but caring for
him is wearing me out." Which ofIth e following response should the
nurse make?

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ANS: "Let's discuss how caring for your father is afollowingecting your
health.

• A nurse is caring for a client who is 4 hr postoperative following a total


thyroidectomy

. Which ofIthe following manifestations should the nurse report to the


provider as indicating possible hypocalcemia?
ANS: Tingling ofIfingers

• A nurse is caring for a client who has a Penrose drain. To ensure proper
placement an d functioning ofIthe drain, which ofIthe following should the
nurse expect to observe? ANS: The safety pin is present at the distal
end ofIthe drain.

• A community health nurse is helping to reinforce teaching about hepatitis


A with a group ofIemployees at a childcare facility. Which ofIthe following
characteristics should t he nurse identify as an external factor that can
impede learning for the participants? ANS: Poor lighting in the learning
setting

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• A nurse is observing newly licensed nurse who is providing tracheostomy


care for a cli ent. The nurse identifies proper performance ofIthe procedure
when the newly licensed nurse selects which ofIthe following solutions to
clean the inner cannula?
ANS: Hydrogen peroxide

• A nurse is caring for a client who has right sided heart failure. The client's
partner exp resses concern the the client will die. Which ofIthe following
responses should the nurse make?
ANS: "It is difollowingicult to see someone so sick. What have you
been told about your partner's prognosis?"

• A nurse is reinforcing discharge instructions with the parent ofIan infant


who has rotav irus. which ofIthe following statements by the parent
indicates an understanding ofIthe teaching?
ANS: "I will apply diaper cream to my baby's skin during each diaper
change."

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• A nurse is caring for a client who is scheduled for surgery in the morning.
The nurse l earns that the client has decided not to have surgery even
though he has already signedthe informed consent form. Which ofIthe
following actions should the nurse take? ANS: Report the situation to
the provider who obtained the informed consent.

• A nurse has to administer medications to a group ofIclients. For which


ofIthe following client situations should the nurse complete and incident
report?
ANS: The nurse administered insulin lispro to a client who has diabetes
mellitusand is NPO.

• a nurse is collecting data from a client who is experiencing a situational


crisis followin g the loss of a job. The client states, I don't think I can go
through this again. Which o fIthe following actions is the nurse's priority?
ANS: Determine ifIthe client is experiencing psychotic thinking.

• A nurse is reinforcing discharge teaching with a client who is 48 hr post op


from a ma stectomy. Which ofIthe following statements by the client
indicates an understanding o fIthe teaching?
ANS: "I will wear rubber gloves whenever I wash dishes or do yard
work."

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• a Nurse is reinforcing teaching about home care for conjunctivitis with the
parent ofIa school age child. which of the following information should
the nurse include?
ANS: Separate the child's used washcloth from those ofIothers.

• A nurse is preparing to insert an indwelling urinary catheter for a female


clientwho has a urinary retention. Which ofIthe following actions should
the nurse take? ANS: Open the outer package flap of the
catheterization kit away from her body.

• A nurse I caring for a client who has expressive aphasia following a


stroke. Which ofIthe following communication methods should the nurse
use?
ANS: Provide a picture board.

• A nurse is caring for a client who is NPO and has an NG tube attached to
sucti on for gastric decompression. Which ofIthe following actions should
the nurse take ifIthe client experiences abdominal distention?
ANS: Irrigate the tube with normal saline.

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• A nurse is assisting with admitting a client who has colorectal cancer.


When C ollecting data from the client, which ofIthe following
manifestations should the nurse expect?
ANS: Abdominal cramps

• A nurse is preparing to administer digoxin to a client who has heart


failure. Wh ich ofIthe following findings should indicate to the nurse that
the medication is efollow ingective?
ANS: Cardiac workload decreases

• A nurse is discussing alopecia with a client who is scheduled to begin


chemoth erapy. Which ofIthe following statements should the nurse
make?
ANS: "Your oncologist may prescribe a cold cap to wear during
treatment to reduce hair loss."

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• A nurse is reinforcing teaching about stress management techniques with


a clie nt who has moderate anxiety disorder. Which ofIthe following
responses by the client indicates an understanding ofIthe teaching?
ANS: "I will imagine myselfIin a calm place when I can't concentrate."

• a nurse is caring forIa female client during an outpatient clinic visit.


Which ofIthe following findings places the client at risk for coronary
artery disease?
ANS: The client's LDL level

• A nurse is reinforcing teaching with a client who is at 20 weeks


ofIgestation an d will undergo routine abdominal ultrasonography the
following day. Which ofIthe foll owing statements should the nurse
include in the teaching?
ANS: "You will need to have a full bladder for the procedure."

• a nurse is reviewing the plan ofIcare for a client who is 3 hr postoperative


follo wing a thyroidectomy. Which ofIthe following is the priority
intervention?
ANS: Listen to the client for evidence ofIstridor.

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• a Nurse prescribes levothyroxine 0.3 PO daily for a client. Available is


levothyroxine 1 50mcg/tablet. How many tablets should the nurse
administer?
ANS: 2

• a nurse is collecting data from an older adult client during a routine


physical exam. W hich ofIthe following client statements should the nurse
identify as a possible indication ofIabuse?

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ANS: "My son took my wallet so he can keep track ofIwhat I'm
spending."

• A nurse is assisting with a presentation at a community center about


personal disaster preparedness. which ofIthe following strategies should
the nurse recommend for preparing a home disaster supply kit?
ANS: Have a supply of prescribed medications.

• A nurse is reinforcing teaching on food selection with a client who has a


moderate burn injury. Which ofIthe following foods should the nurse
recommend as being high inVitamin C.
ANS: Tomatoes

• A nurse on a medical surgical unit is delegating tasks to an assistant.


Which ofIthe following tasks should the nurse delegate to the Assistant?
ANS: Obtaining a client's vital signs prior to discharge

• A Nurse is caring for a client in Buck's Traction. Which ofIthe following


actions should the nurse take?

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ANS: Allow the weights to hang freely.

• A nurse in a long term care facility is contributing to the plan ofIcare for
a client whohas a new ostomy. Which ofIthe following actions should the
nurse plan include?ANS: Change the appliance two times each week.

• A nurse is receiving report on 4 clients Which ofIthe following clients


should the nurse plan to see first.
ANS: A client who has pneumonia and a new onset ofIconfusion

• A nurse is reinforcing discharge teaching with a client who has a t Tube in


place follo wing a cholecystectomy. Which ofIthe following instructions
should the nurse include in the teaching?

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ANS: Empty the drainage bag each day at the same time.

• A nurse is assisting with monitoring a client who is in laborIand has


spontaneous rupture ofImembranes following a vaginal examination. The
provider reports the client's cer vix is dilated to 1 cm with an unengaged
presenting part. Which ofIthe following actio ns should the nurse take?
ANS: Apply the external fetal heart rate monitor.

• A Nurse is collecting data from a client who has bipolar disorder and is
experiencing acute mania. Which of the following findings is the nurse's
priority?
ANS: lack ofIsleep

• A nurse is reinforcing teaching with a client who has a type 2 diabetes


mellitus and re ports waking during the night with tremors and anxiety.
which ofIthe following inform ation should the nurse provide to help the
client manage his symptoms?
ANS: Eat a bedtime snack

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• a Nurse is reinforcing teaching for a client who has a coronary artery
disease and is taking low-
dose aspirin daily. The nurse should include that this medication has
which of the following therapeutic efollowingects for CAD?
ANS: Antiplatelet

• A nurse is collecting data from a client who has an unprepared femur


fracture and rate s his pain as 8 on a scale ofI0 to 10. The client is talking
and caught with a visitor. W hich ofIthe following ofIthe prescribed
medication should the nurse administer?
ANS: Hydromorphone 5 mg orally.

• A nurse is reinforcing preoperative teaching with a client scheduled for a


bowel retenti on with ileostomy. which ofIthe following descriptions should
the nurse give of the ex pected output from a mature ileostomy?

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ANS: liquid with little odor

• A nurse is caring for a client who is 16 hr postoperative following a total hip


arthropla sty. the client reports numbness, pain, and tingling in the
afollowingected leg. Which o fIthe following actions should the nurse take
first?
ANS: compare capillary refill in toes bilateraly

• A nurse is reinforcing teaching with a client who has acute diverticulitis.


Which ofIthe following statements by the client indicates an understanding
ofIthe teaching about the acute phase ofIdiverticulitis?
ANS: "I will receive the nutrient I need through my IV Fluid"

• A nurse in reinforcing teaching with a client about cancer prevention.


The nurse shoul d include that frequent consumption ofIwhich ofIthe
following foods increases the risk ofIcancer?
ANS: Lamb

• A nurse is assisting in teaching a group ofIstafollowing nurses about

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hepatitis A. Whic h ofIthe following modes should the nurse include as a
method ofItransmitting hepatitis A?
ANS: Consumption ofIcontaminated food.

• A nurse is reinforcing teaching with a client who is bottle feeding he full-

term newborn with formula. Which ofIthe following instructions should


the nurse include in the teaching?
ANS: Although is is unnecessary to be rigid about feeding times, six to
eight feedings every 24 hrs should support a full-
term newborn's nutrition adequately. Fewer feedings in the initial
weeks could delay the establishment of an adequate weight-gain
pattern.

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• A nurse is assisting with the plan ofIcare for a client following a


transurethral resectio n ofIthe prostate. Which ofIthe following
interventions should the nurse include in the plan ofIcare?
ANS: The nurse should irrigate the bladder using strict sterile technique
and m aintain closed catheter drainage system to minimize the risk of
infection.

• A nurse is reviewing a client's electronic medical record and finds that an


assistive per sonnel recorder the client's temperature as 35.3 degrees
Celsius (95.5 degrees F) 2 hrs earlier. Which ofIthe following actions
should the nurse take firsT?
ANS: Check the client's temperature.

• A nurse is receiving change-of-

shift report for four clients. Which ofIthe following clients should the nurse
see first?

ANS: A client whose urinary output was 100mL for the past 12 hrs

• A nurse in reinforcing teaching about weight loss with a female older


adult client who is overweight. Which ofIthe following statements should
the nurse include in teaching? ANS: keep fat intake to no more that 30%

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ofIdaily caloric intake.

• A nurse is collecting data from a client who has iron deficiency anemia.
Which ofIthe following findings should the nurse expect?
ANS: Difollowingiculty concentrating.

• A Nurse is collecting data from an older adult client who is 48 hr


postoperative following abdominal surgery. The provider writes a
prescription to advance the client to a re gular Diet. For which ofIthe
following findings should the nurse notify the provider? ANS: The client
has absent bowel sounds.

• A nurse is reinforcing discharge teaching with a client who is


postoperative following transurethral resection ofIthe prostate. Which
ofIthe following instructions should the n urse include in the teaching?

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ANS: perform Kegel exercises daily.

• A nurse is instructing an assistive personnel on the use of proper body


mechanics when moving a client. which ofIthe following statements by the
assistive personnel should the nurse identify as an understanding ofIthe
teaching?
ANS: I will use a pull sheet to help slide the client toward me.

• a Nurse in maintaining droplet precautions for a client who has


meningitis. Which ofIthe following actions should the nurse take?
ANS: Wear a surgical mask within 3 feet of the client.

• A nurse is collecting data from a female client who has a new diagnosis
ofIgenital her pes. Which ofIthe following findings should the nurse
expect?
ANS: Painful erythematous vesicles.

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• a school nurse is having a conversation with the parents ofIan adolescent.


The nurse should identify which ofIthe following situations as an ethical
dilemma for the parents? ANS: "We can't decide whether to try to
homeschool our child or move her to a private school."

• A nurse is preparing to administer prednisone 1mg/kg PO to a


preschooler who weight s 20kg (44lb). Available is prednisone oral
solution 5mg/1mL. How many mL should the nurse administer?
ANS: Round 4 mL

• A nurse is preparing to administer a rectal suppository to a school-

age child. Which ofIthe following action should the nurse plan to take?

ANS: Use one finger to insert the suppository past the anal sphincters.

• A nurse is assisting with monitoring a client who is at 40 weeks


ofIgestation and is in active labor. The nurse recognizes late deceleration
on the fetal monitor tracing. WhichofIthe following actions should the
nurse take?
ANS: Place the client in the lateral position.

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• A nurse manager is providing an in-

service on hand hygiene to assistive personnel. which ofIthe following


information should the nurse manager include in the in-service?
ANS: Remove reigns when washing hand with soap and water.

• A nurse is reinforcing home safety instructions with the parent ofIa


newborn. Which of the following statements should the nurse include in
the instructions?
ANS: Place your baby's crib away from heat vents.

• A nurse is preparing to administer a client's morning medications. Which


ofIthe follow ing actions should the nurse take to verify the client's
identity?
ANS: Scan the facility identification board.

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• A nurse is caring for a client following a bronchoscopy procedure. Which


ofIthe follo wing actions should the nurse perform first?
ANS: Check for a gag reflex.

• While administering a medication to a client, a nurse notices a frayed


electrical cord c onnecting the client's continuous passive motion
machine to the electrical outlet. Whic h ofIthe following actions should
the nurse take?
ANS: Remove the device from the client's room.

• A nurse is caring for a client who requests information bout advance


directives. Which ofIthe following responses should the nurse make?
ANS: "Advance directives are written instructions regarding end-of-life
care."

• A nurse is contributing to the plan ofIcare for a client who is at risk


ofIdeveloping pre ssure ulcers. Which ofIthe following actions should the
nurse include in the plan ofIcar e?

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ANS: Place the client in a 30° lateral position.

• A nurse is assisting with performing a non stress test for a client who is at
39 weeks o fIgestation which ofIthe following instructions should the
nurse reinforce with the client?
ANS: "You should depress the button on the handheld marker when
you feel your baby move."

• A nurse is reinforcing discharge teaching with a client following cataract


surgery. Whi ch ofIthe following instructions should the nurse include in
the teaching?
ANS: Sleep on the nonoperative side for 2 weeks.

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• A nurse manager is preparing to complete a performance analysis for a


group ofIassistive personnel. The manager asks a stafollowing nurse for
feedback on each assistants a bilities. Which ofIthe following actions
should the stafollowing nurse take?
ANS: Discuss how each AP's actions measure against the job description.

• A nurse is preparing to administer a medication to a client when the client


states " I'm sick ofIall there medication. I'm not taking any more today!"
Which ofIthe following a ctions should the nurse take?
ANS: Inform the client of the possible consequences of the medication
refusal.

• a nurse is contributing to the plan ofIcare for a client who is on suicide


precautions. W hich ofIthe following interventions should the
recommend?
ANS: Encourage the client to sign a no-harm contract.

• A nurse is reinforcing reaching for a preoperative client on how to use an


incentive spi rometer. Which ofIthe following actions by the client indicates
an understanding ofIthe teaching?

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ANS: The client attempts to elevate the cylinder by inhaling deeply.

• A nurse at a long term care facility is part ofIa team preparing a report on
the quality ofIcare at the facility. Which ofIthe following information
should the nurse recommendincluding in the report to demonstrate
improvement in care quality?
ANS: The facility had 12% fewer urinary tract infections over the past 6
months.

• A nurse is reviewing laboratory reports for a client who has an


Escherichia Coli infection and is receiving gentamicin. Which ofIthe
following results should the nurse report to the provider before
administering the next dose?
ANS: Creatinine 2.5 mg/dL

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• A nurse working in a community clinic is caring for an adolescent who has


infectious mononucleosis. The client asks the nurse to explain how the
disease was acquired. The nurse should explain that an individual acquires
this disease by which ofIthe following
.

ANS: Sharing eating utensils with an infected person

• A nurse is reinforcing teaching with a client who has hypothyroidism and


a prescriptio n for levothyroxine. Which ofIthe following instructions
should the nurse include in the teaching?
ANS: "You will need to take the medication for the rest of your life."

• A nurse is collecting data from a postpartum client who had a vaginal birth
2 days ago

. Which ofIthe following findings is the nurse's priority to report to the


provider?

ANS: Client reports during with urination.

• A nurse is reinforcing reaching with a client about a planned


thoracentesis. Which ofIt he following information should the nurse

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include in the teaching?
ANS: You will need to be monitored for 1 hour after the procedure."

• A nurse is contributing to the plan ofIcare for an older adult client who
has difollowingiculty sleeping. Which ofIthe following interventions
should the nurse include in the plan?
ANS: Establish a regular exercise routine 2 hr or more before bedtime.

• A nurse in a provider's ofollowingice is reinforcing teaching with a client


who has a ne w prescription for ferrous sulfate elixir. Which of the
following statements by the clien t should indicate to the nurse an
understanding ofIthe teaching?
ANS: I will rinse my mouth after taking this medication.

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• A licensed practical nurse on a medical surgical unit is working with an RN


and an As sistive personnel. Which ofIthe following assignments should
the LPN expect to receive?
ANS: Administering an NG tube feeding to a client who had a stroke

• A nurse is caring for a client who has schizophrenia and is experiencing


auditory hallu cinations. Which ofIthe following actions should the nurse
take?
ANS: Ofollowinger the client headphones to listen to music.

• A nurse is reinforcing teaching with a client about taking warfarin to treat


atrial fibrillation. Which ofIthe following statements by the client indicates
an understanding ofIthe teaching?
ANS: If I forget to take a dose, I can take it later on the same day."

• A nurse is working with an interpreter to explain a diagnostic procedure


to a client wh o doesn't speak the same language as the nurse. Which
ofIthe following actions should the nurse take?
ANS: Ensure the interpreter is culturally compatible with the client.

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• A nurse is reinforcing discharge teaching with a client who has


dependent personality disorder. Which ofIthe following instructions
should the nurse include in the dischargeteaching?
ANS: Demonstrate assertiveness.

• A nurse is contributing to the discharge plan for a client who had a knee
arthroplasty.Which ofIthe following actions should the nurse identify as
the priority?
ANS: Check the client's mobility

• A nurse in a long-

term care facility is assisting with the admission ofIa client who requires
oropharyngeal suctioning. Which ofIthe following supplies does the nurse
need to perform this task?

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ANS: Yankauer catheter

• A nurse is collecting data from a client who is 24 hr post op from an open


colon resection, has a clamped NG tube, and is resuming a clean liquid
diet. Which ofIthe following findings should the nurse report to the
provider?
ANS: Client reports vomiting green-tinged fluid.

• A nurse is caring for a client who took an overdose ofIacetaminophen.


Which ofIthe following medications should the nurse plan to administer
to the client?
ANS: Acetylcysteine

• A nurse delegates the collection ofIa sputum specimen from a client who
has tu berculosis to an assistive personnel. At which ofIthe following times
should the nurse i nstruct the ap to collect the specimen?
ANS: As soon as the client wakes up.

• A nurse in a long term care facility is using validation therapy with a client
wh o has dementia. The client becomes agitated and asks why his wife
who died several y ears ago has not visited him. Which ofIthe following

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responses should the nurse make?ANS: You must miss your wife. Let's
take a walk and you can tell me about he r.

• A nurse is reinforcing teaching with a client who has a prescription for


nitrogly cerin sublingual tablets Which ofIthe following instructions should
the nurse include in the teaching?
ANS: Take up to three tablets during a single angina episode.

• a Nurse is caring for a client who is post op following an open reduction


with i nternal fixation ofIthe ankle. The client report pain and the nurse
notes that the afollow ingected extremity is cool, pale, and has a weak
pulse. The nurse calls the surgical assi stant who responds "it has always
been like that" Which ofIthe following actions shoul d the nurse take
first?

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ANS: Notify the nursing supervisor.

• a nurse is collecting data from a client who has Tourette syndrome. The
client r eports taking haloperidol 0.5 mL orally 3 times a day at home.
Which ofIthe following components ofIthe prescription should the nurse
question?
ANS: Dosage

• A nurse is caring for a female client who has an indwelling urinary


catheter. w hich ofIthe following actions should the nurse take?
ANS: Wipe the drainage port with an antiseptic wipe after emptying urine
from bag.

• A nurse is reinforcing teaching with a newborn's parents about umbilical


cord c ard. Which ofIthe following statements by a parent indicates an
understanding ofIthe in struction?
ANS: "I will give our baby sponge baths until the cord falls ofollowing."

• A nurse who is facilitating a support group notices that one client in the
group i s extremely talkative, to the point where others in the group have

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difollowingiculty sha ring their own ideas. Which ofIthe following
strategies should the nurse use to facilitat e the group process with this
client?
ANS: Speak privately to the client about this behavior.

• A nurse at a clinic is performing vision testing for a client following a head


inj ury. Which ofIthe following findings should the nurse identify as a
problem with pupil accommodation?
ANS: Lack of change in pupil size when the client looks from a far to a
near object.

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• A nurse is reinforcing teaching with a client who has cancer and a new
prescrip tion for fentanyl transdermal patches. Which ofIthe following
statements by the client i ndicates an understanding ofIthe teaching?
ANS: "I will fold the patch with the adhesive sides inward before
discarding it."

• A nurse is contributing to the plan ofIcare for a client who had a vaginal
delive ry 4 hours ago and has a 4th degree perineal laceration. Which
ofIthe following action s should the nurse recommend?
ANS: Instruct the client to use a sitz bath at least twice a day.

• A nurse is collecting data from a client who sustained spinal cord injuries
from fractures to the t1 and t2 vertebrae. Which ofIthe following client
outcomes should the nurse expect?
ANS: Flexes and extends the shoulders

• A nurse is preparing to administer an influenza virus immunization to a


client b y the intradermal route. Which ofIthe following actions should the
nurse take?
ANS: Avoid massaging the site after injecting the vaccine

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• A nurse assisting with a childbirth class is discussing non pharmacological


strat egies used during labor. Which ofIthe following statements by a client
indicates an und erstanding ofIcutaneous stimulation?
ANS: "I should use counterpressure for back pain during labor."

• A nurse is assisting with the admission ofIa client who has major depressive
dis order. Which ofIthe following communication technique should the
nurse use to establish a trusting relationship with the client?
ANS: Ofollowingering general leads

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• A nurse is preparing to administer medications to a client who is NPO and is


re ceiving enteral feedings through an NG tube. Which ofIthe following
prescription should the nurse clarify with the provider?
ANS: Metoprolol ER 50mg per NG tube BID

• A nurse is contributing to the plan ofIcare for a client who is newly


diagnosed with iron deficiency anemia. Which ofIthe following foods
should the nurse include in the plan as having the highest amount
ofIiron?
ANS: Boiled spinach

• A nurse is administering lorazepam to a client who is scheduled for


surgery within 1 yr. Which of the following actions should the nurse take
after administering the medication ?
ANS: Instruct the client not to get out of bed.

• A nurse is observing an AP caring for a client. For which ofIthe following


actions should the nurse intervene?
ANS: An AP reports client information to the oncoming AP in the
hallway

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• A nurse is observing a stable preterm newborn who develops apnea for


longer t han 20 sec, with a decrease heart rate ofI20/min. Which ofIthe
following actions shoul d the nurse take first?
ANS: Flick the sole ofIthe newborn's foot

• A nurse is assisting in the plan ofIcare for a female client who is to


undergo a12-
lead ECG. Which ofIth ofollowing actions should the nurse include in the
plan ofIcare

ANS: Instruct the client to remain still while the test is performed.

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• A nurse in a long term care facility is reviewing information about health


care associated infection with a newly licensed nurse. Which ofIthe
following information should the nurse include?
ANS: Prolonged use of corticosteroids is a risk factor for infection.

• A nurse is collecting data on a client who has post traumatic stress disorder
Wh ich ofIthe following manifestations should the nurse expect?
ANS: Hypervigilance

• A nurse is caring for a client who has multiple sclerosis. Which ofIthe
following manifestations should the nurse expect?
ANS: Ataxia

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• A nurse is checking a newborn's vital signs. Which ofIthe following


methods of temperature measurement should the nurse use?
ANS: Axillary

• A nurse in a provider's ofollowingice is collecting data from a preschooler.


Which ofIthe following findings should the nurse report to the provider?
ANS: Heart rate 146/min

• A nurse is preparing to discharge a middle adult client who is


immunocomprom ised. Which ofIthe following immunizations should the
nurse plan to administer?
ANS: Pneumococcal polysaccharide (PPSV) vaccine

• A nurse is caring for a client who had a bone marrow transplant 3 days ago
for treatment for leukemia. Which ofIthe following findings should the
nurse identify as a safety hazard?
ANS: A visitor brought the client a bouquet ofIflowers.

• A nurse is caring for an infant who is receiving IV fluids for dehydration.

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Whic h ofIthe following should the nurse recognize as a positive response
to therapy?
ANS: Moist mucous membranes

• A nurse is preparing a client for surgery. The client states, "I'm sure this
surger y will not help me get better" Which ofIthe following responses
should the nurse make
?

ANS: "You're saying that you are doubtful that this procedure will
benefit you."

• A nurse at a long term care facility is transcribing new prescriptions


for 4 client

s. Which ofIthe following prescriptions is accurately transcribed by the


nurse?

ANS: Potassium chloride 20 mEq PO every morning

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• A charge nurse in a long term care facility notices an assistants repeated


failure to provide oral care for clients. Which ofIthe following actions
should the nurse take? ANS: Discuss the unacceptable behavior with the
AP while reinforcing expectati ons.

• A Nurse is reinforcing teaching with a male client who is uncircumcised


aboutobtaining a clean-
catch midstream urine specimen. Identify the sequence ofIactions the
client should takeafter washing his hands.
ANS: Retract the foreskin to expose the
glanscleanse the penis using an
antiseptic swabBegin to urinate
pass the urine container into the
streamcollect the specimen
move the container out ofIthe
streamReplace the foreskin

• A nurse is reinforcing teaching with a client who has a new diagnosis


ofItype 2diabetes mellitus and inquires about information concerning oral
anti diabetic agents. I n addition to the provider, where should the nurse
refer the client for information? ANS: A pharmacist
Package inserts

American Diabetes Association

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• A nurse is caring for four clients who are all scheduled for surgery on the
same day. Which of the following nursing actions demonstrates that the
nurse possesses efo llowingective time management skills?
ANS: Gathers all needed supplies and equipment before entering client
rooms Completes one task before beginning a new task
Documents the clients' preoperative vital signs when they are
taken

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Delegates tasks to an assistive personnel (AP) that are within his


range offunction

• A nurse in a long term care facility is serving on the ethics committee,


which is addressing a client care dilemma. Which ofIthe following strategies
will facilitate reso lving the dilemma?
ANS: Determine the facts related to the dilemma.

Identify possible
solutions. Consider the
client's wishes.

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