2024 Exit Comprehensive Retake Exam New Latest Version Best Studying Materials, Exams of Nursing

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2024 ATI Exit Comprehensive Retake Exam New

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A nurse is reinforcing teaching to the support person of the client who has early stage labor. Which of the following instructions should the nurse include regarding effleurage? ---------- Correct Answer ----------- Gently stroke her abdomen during contractions A nurse is caring for an older adult client who is postop following a total hip arthroplasty. The client is incontinence of stool and urine. Which of the following actions should the nurse take to prevent skin breakdown? ---------- Correct Answer ----------- Used a moisture barrier on the client's skin A nurse is contributing to the POC who has herpes simplex. The nurse should plan to initiate which of the following isolation precautions when caring for this client? ---------- Correct Answer ----------- Contact precautions A nurse is documenting client care in the nurses and notices that a space was left blank. Which of the following actions should the nurse take? ---------- Correct Answer ---- ------- Draw a horizontal line through the space and sign at the end of the line A nurse is collecting data from a client who has heart failure the nurse notices the client has crackles in the bases of the lungs shortness of breath and a respiratory rate of 24 bom which of the following actions should the nurse take ---------- Correct Answer --------

• Maintain the client and high Fowlers position A home health nurse is conducting a home inspection for a client who is it was for falls which of the following instruction should the nurse provide for the client ---------- Correct Answer --------- Move the clients bed to the main floor on the house A nurse in an acute mental health facility is caring for an adolescent who is exhibiting destructive behavior which of the following actions should the nurse take after applying physical restraints to the Client ---------- Correct Answer --------- Plan to remove the restraints as soon as the client is calm A nurse is caring for a client who has AIDS. Which of the following solutions should the nurse disinfect the client's overhead table following a blood spill? ---------- Correct Answer ----------- Bleach A nurse is caring for a client who has terminal cancer. Which of the following instructions should the nurse take to promote the client's autonomy? ---------- Correct Answer ----------- Allow the client to choose treatment times

A nurse in a clinic is caring for a client who is at 40 weeks gestation and experiences a sudden gush of vaginal fluids. Which of the following findings is evidence of an obstetric complication? ---------- Correct Answer ----------- Appears greenish-brown in color A nurse is assisting w the care of an adolescent client immediately following a lumbar puncture. Which of the following actions should the nurse take? ---------- Correct Answer ----------- Inform the adolescent that he might experience a headache A nurse is reinforcing teaching about advance directives w a client who has end stage renal heart failure. Which of the following statements by the client indicates an understanding of the teaching? ---------- Correct Answer ----------- "I should discuss this document with my family after I sign it" A nurse is caring for a client who has a continuous bladder irrigation following a TURP. The nurse notices clots and dark red blood in the catheter collection bag. Which of the following actions should the nurse take? ---------- Correct Answer ----------- Irrigate the bladder with 20-30 ml of 0.9% sodium chloride irrigation A nurse is planning to obtain a 12-lead ECG for a client who has a history of cardiac dysrhythmias. Which of the following actions should the nurse plan to take? ---------- Correct Answer ----------- Instruct the client to remain as still as possible during the recording A nurse is reinforcing teaching w a client who has genital herpes. Which of the following info should the nurse include in the teaching? ---------- Correct Answer ----------- You should increase fluid intake to relieve dysuria A nurse is preparing to empty a postop client's closed-wound drainage system. Which of the following actions should the nurse plan to take? ---------- Correct Answer ----------- Compress the container before replacing the drainage bag A nurse is reinforcing teaching w the parents of a toddler who has a new diagnosis of asthma and a prescription of Montelukast. Which of the following instructions should the nurse include in the teaching? ---------- Correct Answer ----------- Administer the medication to the toddler each evening A nurse in an acute mental health facility is caring for a newly admitted client. Which of the following should occur during the orientation phase of the nurse-client relationship? - --------- Correct Answer ----------- Defining responsibilities A nurse is caring for a client who reports having a decrease in fetal movement following an external cephalic version 6 hr ago. The nurse identifies the fetus is in the right occiput anterior position. The nurse should place a fetal heart monitor on which of the following sites to auscultate the fhr? ---------- Correct Answer ----------- Lower left

A charge nurse is observing a newly licensed nurse perform suctioning for a client who has a tracheostomy. For which of the following actions by the newly licensed nurse should the charge nurse intervene? ---------- Correct Answer ----------- Suctions for 30 seconds A nurse is reviewing the MAR of a client who takes atenolol PO and supplies a nitroglycerin transdermal patch daily. Which of the following interactions should the nurse monitor with this client? ---------- Correct Answer ----------- Hypotension A nurse in an acute care setting is preparing to administer meds to a client. Which of the following actions should the nurse verify the client's identity? ---------- Correct Answer --- -------- Verify the client's identity using a photograph A nurse in a provider's office is collecting data from a client who has psoriasis. Which of the following statements made by the client should report to the provider? ---------- Correct Answer ----------- "I try not to look at the scales on my body" A nurse is completing chart reviews in a ltc facility in response to an increase in falls. Which of the following responses in the chart should the nurse use it to determine the potential causes of falls? ---------- Correct Answer ----------- Medication record A nurse is making client care assignments for an AP. Which of the following tasks should the nurse assign to the AP? ---------- Correct Answer ----------- Complete post mortem care for a client who has died A nurse is reinforcing teaching w a client who is taking allopurinol about the risk for developing Stevens-Johnsons syndrome. For which of the following manifestations should the nurse instruct the client to monitor and report? ---------- Correct Answer ------- ---- Skin rash w fever A charge nurse in a long term facility is reinforcing teaching w a group of nurses about fall precautions. Which of the following statements made by the nurse indicates an understanding of the teaching? ---------- Correct Answer ----------- "I will instruct the client to sit when putting on a pair of pants" A nurse is recommending clients for d/c to allow for admission of clients following a tornado disaster. Which of the following clients should the nurse recommend for d/c? --- ------- Correct Answer ----------- A client who has a sodium level of 140 mEq/L after one episode of diarrhea A nurse is assisting w the POC for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? ---------- Correct Answer ----------- Administer liquid supplements A charge nurse is reinforcing teaching w a newly licensed nurse about floating to a different unit. Which of the following statements by the newly licensed nurse indicates

an understanding of the teaching? ---------- Correct Answer ----------- "I will document in the medical record the support nurse who assists w planning care for my clients" A nurse is caring for a client who has dehydration due to diarrhea. Which of the following findings should the nurse report to the provider? ---------- Correct Answer ------- ---- BUN 18 mg/dL A nurse is participating in a performance improvement program. Which of the following actions should the nurse take to evaluate the effectiveness of the program? ---------- Correct Answer ----------- Identify data collection methods A nurse is an assisted living facility is reinforcing teaching w staff members about preparing for an external chemical disaster. Which of the following instructions should the nurse include? ---------- Correct Answer ----------- Move clients to a room above ground with a few windows A nurse is assisting in the care of a client who has an AV shunt in his right arm. Which of the following actions should the nurse take? ---------- Correct Answer ----------- Avoid range of motion in the right arm A nurse is caring for a client who has been admitted to the mental health unit. While reinforcing teaching about the client's prescribed exacerbations, the nurse communicates truthfully about the adverse effects of the medication. Which of the following ethical concepts is the nurse exhibiting? ---------- Correct Answer ----------- Veracity A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. The nurse should place the client in which of the following positions? ---------- Correct Answer ----------- Semi-fowler's A nurse is reinforcing teaching w the parents of a child who has a new diagnosis of Wilms tumor. Which of the following interventions should the nurse include in the teaching? ---------- Correct Answer ----------- "You should not palpate your child's abdomen prior to surgery" A nurse enters the room of a school-age child and finds him on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? ---------- Correct Answer ----------- Place a pillow under the child's head A nurse is contributing to the POC of a client who is to begin receiving intermittent enteral feedings. Which of the following actions should the nurse recommend? ---------- Correct Answer ----------- Place the client in high-fowler's position during feedings A nurse is collecting data from a client in an outpatient clinic and observes extensive bruising on the client's arm's. The nurse suspects the client is experiencing intimate

partner abuse. Which of the following is the nurse's priority action? ---------- Correct Answer ----------- Provide information about moving to a shelter A nurse in an urgent care clinic, recently using methylenedioxy-methamphetamine. Which of the following findings should the nurse expect? ---------- Correct Answer --------- -- Hallucinations A nurse is reinforcing teaching w a client who has a prescription for ferrous sulfate elixir. Which of the following statements by the client indicates an understanding of the teaching? ---------- Correct Answer ----------- I will mix the medication w water A nurse is collecting data from a client who received oxytocin 10 units IM 30 mins ago for excessive vaginal bleeding. Which of the following findings should the nurse expect? ---------- Correct Answer ----------- Boggy fundus 3 fingerbreadths above the umbilicus A nurse is attending an educational workshop about client confidentiality. Which of the following actions by the nurse indicates an understanding of the teaching? ---------- Correct Answer ----------- Changes her personal login password at random times A nurse is assisting w d/c planning for a group of clients. Which of the following clients should the nurse recommend a home health referral? ---------- Correct Answer ----------- An older adult client who has heart failure and lives alone A nurse is reinforcing teaching w a female client who is taking phenytoin. Which of the following instructions should the nurse include in the teaching? ---------- Correct Answer ----------- You might experience swollen gums while taking this medication A nurse is preparing to administer paroxetine 15 mg/PO oral suspension to a client who has a depressive disorder. The amount available is 10 mg/5mL. How many mL should the nurse administer (Round to nearest tenth) ---------- Correct Answer ----------- 7.5 mL A nurse is reinforcing teaching w a client who is at 38 week's gestation and it to undergo a contraction stress test. Which of the following statements by the client indicates an understanding of the teaching? ---------- Correct Answer ----------- I am having this test because my baby was not reactive during a nonstress test A nurse is discussing health practices with a mother of a toddler who is from a different cultural background than the nurse. Which of the following statements by the mother indicates that she practices cupping? ---------- Correct Answer ----------- I sometimes place a bottle containing team against the child's skin A nurse is reinforcing teaching w a client who has primary open-angle glaucoma and has a prescription for timolol eye drops. Which of the following statements by the client indicates an understanding of the teaching? ---------- Correct Answer ----------- I should check heart rate while taking this medication

A nurse is collecting data from a preschooler who has severe dehydration. Which of the following findings should the nurse expect? ---------- Correct Answer ----------- Weight loss 10% A nurse is contributing to the POC for an older adult client. Which of the following physiological changes should the nurse consider when administering medication? ------- --- Correct Answer ----------- Decreased kidney function A nurse is caring for a client who is taking multiple medications and asks about possible interactions. To which of the following members of the idt should the nurse make a referral? ---------- Correct Answer ----------- Advanced practice nurse A nurse is collecting data from a client who just received his first dose of sulfasalazine to treat ulcerative colitis. Which of the following findings should the nurse identify as an indication of an allergy reaction to this medication? ---------- Correct Answer ----------- Dyspnea A nurse is collecting nutritional data from a group of adult clients. For which of the following clients should the nurse recommend an interpersonal care conference w a dietitian? ---------- Correct Answer ----------- A client who has a bmi of 32 A charge nurse is reinforcing teaching w a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? ---------- Correct Answer ----------- Soiled dressings should be places in a biohazard trash receptacle A nurse is preparing to administer Vitamin K to give to a newborn. The newborn's mother questions the purpose of this medication. Which of the following responses should the nurse make? ---------- Correct Answer ----------- This medication will decrease the risk of hemorrhage in your newborn A nurse is collecting data from a client who has dka. Which of the following findings should the nurse report to the provider? ---------- Correct Answer ----------- Fruity breath odor A nurse is caring for a client who has a vacuum-assisted closure system to treat a pressure ulcer. Which of the following actions should the nurse take? ---------- Correct Answer ----------- Use an adhesive remover to remove tape before applying dressing A nurse is caring for a client who has a recent diagnosis of a terminal illness. The nurse should identify which of the following as an indication of hopelessness? ---------- Correct Answer ----------- The client has a decreased level of energy A nurse is preparing to collect data on a preschooler. Which of the following behaviors by the child indicates that he is ready to cooperate? (SATA-3) ---------- Correct Answer -- --------- 1. Allows the nurse to touch him on the arm

2. Answers questions asked by the nurse
3. Makes eye contact with the nurse A nurse on a mental health unit is planning care for a group of clients. Which of the following clients should the nurse see first? ---------- Correct Answer ----------- A client who has schizo and is having command hallucinations A nurse is caring for a client who recently gave birth to her first child. The newborn is crying and the client states, "I can't seem to do anything right. What should I do?" Which of the following responses should the nurse make? ---------- Correct Answer ----------- "Let me show how to swaddle and cuddle him, then try." A nurse is using a glucometer to measure a client's capillary blood glucose level. Which of the following actions should the nurse take? ---------- Correct Answer ----------- Keep the finger in dependent position A nurse is reviewing the home medications with a client who recently had a transient ischemic attacks and is to begin taking clopidogrel. The nurse should instruct the client that which of the following otc meds interact adversely w clopidogrel? ---------- Correct Answer ----------- Naproxen A nurse is collecting data from a client who has a long leg cast that was applied 2 days ago. The client's foot is pale w a weak pedal pulse and the client reports foot numbness. Which of the following actions should the nurse take first? ---------- Correct Answer ------- ---- Check for pain w passive movement of the affected extremity A nurse in a providers office is reinforcing teaching about cigarette smoking w a client. Which of the following adverse effects should the nurse include in the teaching? ---------- Correct Answer ----------- Somnolence A nurse is contributing to the development of an in-service program for mental health nursing staff. The nurse should include that the staff can medicate a client against his will, without a court hearing in which of the following situations? ---------- Correct Answer ----------- A client who is attempting to hurt himself or others A nurse is reinforcing teaching with a client who has a new prescription for digoxin. Which of the following instructions should the nurse include in the teaching? ---------- Correct Answer ----------- "Monitor for muscle weakness while taking the medication" A charge nurse is discussing confidentiality requirements w a newly licensed nurse when sharing a client's medical info. Which of the following individuals should the charge nurse identify as appropriate with whom to share client info? ---------- Correct Answer ----------- A social worker who's assigned an involuntary committed school-age client

A nurse is reviewing lab values for a client who is at 34 weeks of gestation. Which of the following findings should the nurse report to the provider? ---------- Correct Answer ------- ---- Urine protein plus A nurse is collecting data from a client who is 4 hr postop following a hemicolectomy. Which of the following findings is a nurse's priority, requiring immediate intervention? ---- ------ Correct Answer ----------- O2 sat 89% A nurse in a provider's office is collecting data from a client who has a history of hypertension during his annual physical examination. Which of the following findings should the nurse report to the provider immediately? ---------- Correct Answer ----------- Blurred vision A nurse is caring for a client who suddenly develops chest pain and dyspnea. Which of the following actions should the nurse take first? ---------- Correct Answer ----------- Elevate the client's HOB A nurse is reinforcing teaching on a client who has diabetes mellitus. Which of the following lab tests is most accurate of blood glucose effective management? ---------- Correct Answer ----------- Glycoslated Hemoglobin A nurse charge on a mental health unit is supervising a newly licensed nurse. For which of the following actions by the newly licensed nurse should the supervising nurse intervene? ---------- Correct Answer ----------- Tells a client he will lose his phone privileges if he does not take his medication A nurse is supervising an AP obtain supplies for a client who is on seizure precautions. Which of the following materials should the AP place in the client's room? ---------- Correct Answer ----------- Oral suction equipment A nurse is reinforcing discharge teaching with a family of a client who has dependent personality disorder. What action should the nurse take? ---------- Correct Answer -------- --- Encourage client to be assertive A nurse is reinforcing discharge teaching with a client who had a right total hip arthroplasty. Which of the following instructions should the nurse indicate? ---------- Correct Answer ----------- "You should avoid crossing your legs for 3 months" A nurse is reinforcing dietary teaching with a client who has hyperemesis gravidarum. Which of the following instructions should the nurse include in the teaching? ---------- Correct Answer ----------- Eat a small meal every 2-3 hr A nurse is reinforcing teaching with a client who has GERD and a prescription for ranitidine. Which of the following statements by the client indicates and understanding of the teaching? ---------- Correct Answer ----------- "I should take this medication in the morning and at night"

A nurse is assisting with the admission of a client who has pulmonary tb. Which of the following types of isolation precautions should the nurse include? ---------- Correct Answer ----------- Airborne A nurse is reinforcing discharge teaching with a client who has COPD and reports problems with maintaining adequate nutrition. Which of the following instructions should the nurse include? ---------- Correct Answer ----------- "Perform pulmonary hygiene 1 hr before meals" A nurse is administering pancreatic enzymes to a client who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effects of the treatment? ---------- Correct Answer ----------- Reduced fat in stools A nurse is caring for a client who has paranoid schizo and believes that she is being followed by FBI agents who are pretending to be the psychiatric staff. Which of the following responses should the nurse make? ---------- Correct Answer ----------- The psychiatric staff not the FBI. They're here to help you A nurse is assisting in the care of a client who has a fractured femur and is in Buck's traction, which of the following actions should the nurse take? ---------- Correct Answer -- --------- Ensure the weights are hanging freely A nurse is reviewing the med record of a client who requires continuous oxygen saturation monitoring. Which of the following should the nurse identify as a factor that can affect the validity of the readings? ---------- Correct Answer ----------- Peripheral Vascular Disease A nurse is collecting data from a group of clients. Which of the following clients should the nurse identify as having xanthelasama? ---------- Correct Answer ----------- Lady with eyes closed with nodule on eyelid A nurse is assisting with the admission of a client who has VRE of the urine. Which of the following types of precautions should the nurse implement for this client? ---------- Correct Answer ----------- Contact precautions A community health nurse is assisting in the development of a brochure about hypertension. Which of the following actions should the nurse take? ---------- Correct Answer ----------- Explain medical terminology using basic one-syllable words A nurse is collecting data from an adolescent during an annual physical examination. Which of the following statements by the client is the nurse's priority? ---------- Correct Answer ----------- I would rather be alone than with my fiance

A nurse is placing a dressing over a stage 1 pressure ulcer on a client's heel. Which of the following types of wound dressing should the nurse use? ---------- Correct Answer --- -------- Transparent film A nurse is caring for an older adult client who reports pain and has a prescription for ketorolac 15 mg IM every 5 hr PRN. The client's current bp is 114/55 mm Hg. Which of the following actions should the nurse take? ---------- Correct Answer ----------- Administer the medication to the client A charge nurse in a LTC is developing a performance improvement plan for an AP. Which of the following actions should the nurse take when developing the plans? (SATA-3) ---------- Correct Answer ----------- 1. Set a specific time frame for meeting performance goals

2. Ask the nurse supervisor to review to plan
3. Include the performance standard that the AP should meet A nurse is reinforcing teaching with a client who is undergoing radiation therapy to the neck. Which of the following instructions should the nurse include in the teaching? ------- --- Correct Answer ----------- Avoid exposing the neck to the cold A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following fall precautions should the nurse plan to implement? ---------- Correct Answer ----------- Determine the client's ability to use the call light A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. Which of the following info should the nurse include in the teaching? ---------- Correct Answer ----------- "You will need to urinate before the procedure" A nurse is caring for a client who has terminal cancer and has declined treatment. The nurse attempts to convince the client to reconsider his decision and discusses this attempt w the charge nurse. Which of the following actions should the charge nurse take? ---------- Correct Answer ----------- Talk with the nurse about the need to support the client's decision A nurse is reinforcing teaching about breastfeeding w a client who gave birth 2 days ago. Which of the following info should the nurse include? ---------- Correct Answer ------- ---- Feed newborn 8-12 times/day every 24 hr A nurse is assisting w the admission of a school aged child. Which of the following actions should the nurse plan to take? (Exhibit) ---------- Correct Answer ----------- Initiate contact precautions for the child

A nurse is contributing to the POC for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend to include in the plan? ---------- Correct Answer ----------- Measure the client's abdominal girth daily A nurse is reinforcing teaching w a client who has a prescription for antibiotic therapy. The client tells the nurse that he always experiences diarrhea when he takes antibiotics. Which of the following food choices should the nurse recommend to lessen the occurrence of diarrhea? ---------- Correct Answer ----------- Yogurt A nurse is assisting with the care of a client who has ICP followed a closed head injury. Which of the following actions should the nurse take? ---------- Correct Answer ----------- Elevate HOB 30 degrees A nurse is assisting with the plan of care for a client who is in the 3rd trimester of pregnancy and has ankle edema. Which of the following interventions should the nurse include in the client's plan of care? ---------- Correct Answer ----------- Apply support stockings A nurse is contributing to the POC for a client experiencing delirium. Which of the following interventions should the nurse recommend? ---------- Correct Answer ----------- Remind the client of the day and time often A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers. Which of the following foods should the nurse include? ---- ------ Correct Answer ----------- Grapes A nurse is reinforcing dc teaching with a client who has a new diagnosis of tb. Which of the following instructions should the nurse include in the teaching? ---------- Correct Answer ----------- "You should have a sputum examination every 4 weeks" A nurse is assisting w the care of a client who is at 37 weeks gestation and is undergoing a nonstress test. Which of the following actions should the nurse take? ------ ---- Correct Answer ----------- Remind the client to press the button when she feels fetal movement A nurse is contributing to the POC for a client who has dysphagia. Which of the following interventions should the nurse include? ---------- Correct Answer ----------- Tile the client's head forward during meals A nurse is reinforcing teaching w a client who is at 18 weeks gestation and has a medical history of mild hypertension. For which of the following findings should the nurse instruct the client to monitor and report to the provider? ---------- Correct Answer -- --------- Persistent headache

A nurse is talking with the partner of a client who recently died. Which of the following statements should the nurse take? ---------- Correct Answer ----------- "Tell me what I can do for you at this time" A nurse is assisting w the admission of a client who states, "The last time I was in the hospital, the nurses took forever to answer my call light" Which of the following is an appropriate response by the nurse? ---------- Correct Answer ----------- "That must have been a difficult experience for you" A nurse in a provider's office is caring for a group of clients who have communicable diseases. Which of the following infections should the nurse report to the state health department? ---------- Correct Answer ----------- Neisseria gonorrhoeae A nurse is assisting with the admission of an adolescent client who is suspected to have bacterial meningitis. Which of the following findings should the nurse expect? ---------- Correct Answer ----------- Nuchal rigidity A nurse is reviewing lab findings for 4 clients. Which of the following lab values is an expected findings for a client who has end stage renal disease? ---------- Correct Answer ----------- Creatinine 15 mg/dL A nurse is caring for a client who is taking warfarin and has an INR of 5.5. The nurse should expect which of the following instructions from the provider? ---------- Correct Answer ----------- 1. Obtain an aPTT level A nurse is assisting w the care of a client who is receiving a continuous IV infusion. Which of the following indicates fluid volume excess? ---------- Correct Answer ----------- Distended neck veins A nurse is reinforcing teaching w the parents of an infant who has a Pavlik harness. Which of the following statements should the nurse include in the teaching? ---------- Correct Answer ----------- "The harness can promote hip joint development" A nurse is caring for a client who is 2 days postop. The client has a prescription for acetaminophen 300 mg w codeine 30 mg. 1 tablet every 3-4 hr PRN for pain. The nurse inadvertently administers 2 tablets to the client in which of the following locations should the nurse document this error? ---------- Correct Answer ----------- Incident report A nurse is preparing a sterile field to perform a dressing change for a client's leg wound. Which of the following actions should the nurse take? ---------- Correct Answer ----------- Place sterile objects at least 2.5 cm (1 in) from the edge of the sterile field? A nurse begins to bath a newly admitted client who reports that she has not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. The action by the nurse is an example of which of the following? ---------- Correct Answer ----------- Countertransference

A home health nurse is caring for an older adult client who has RA. Which of the following findings should the nurse identify as a safety risk? ---------- Correct Answer ----- ------ The client's electrical wires are running under the carpet A nurse is reinforcing teaching w a client who is about to undergo surgery. Which of the following statements about informed consent should the nurse include in the teaching? - --------- Correct Answer ----------- You can sign the informed consent form after the provider explains the pros and cons of the procedure A nurse is reinforcing teaching with a client who has trichomoniasis vaginalis infection and a new prescription for metronidazole. Which of the following instructions should the nurse include in the teaching? ---------- Correct Answer ----------- You should expect your urine to turn brown A nurse is obtaining informed consent from a client who is scheduled for an invasive procedure. The client states, "I don't understand why this procedure is necessary" Which of the following actions should the nurse take? ---------- Correct Answer ----------- Remind the client about the specifics of the procedure A nurse is reviewing info about advanced directives w a newly admitted client. Which of the following statements by the client indicates an understanding of the info? ---------- Correct Answer ----------- "Advances directives include a living will" A nurse is collecting data from the caregiver of a client who has Alzheimer's disease. The caregiver reports the client has difficulty sleeping at night and wanders throughout the house. Which of the following interventions should the nurse recommend? ---------- Correct Answer ----------- Encourage the client to take frequent walks during the day A nurse is assisting in the care of a client who is 8 hr postpartum and has uterine atony with increased bleeding. Which of the following actions should the nurse take? (SATA-

1. ---------- Correct Answer ----------- Assist the client to empty her bladder A nurse is verifying informed consent for a client who is postop from a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent? ---------- Correct Answer ----------- I am thankful I am done having children A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? ---------- Correct Answer ----------- Measure the duration of the seizure A nurse is collecting data from a client who is at 12 weeks gestation. The client states, "We've been trying to get pregnant for several months, but now I'm not sure I'm ready" Which of the following responses should the nurse make? ---------- Correct Answer ------- ---- Many women experience feelings of ambivalence during pregnancy

A nurse is caring for 4 clients. Which of the following situations require a signed consent form? ---------- Correct Answer ----------- Administering an iron injection z-track method A nurse is receiving areporton for clients. The nurse should plan to collect data from which of the following clients first? ---------- Correct Answer ----------- A preschooler who has epiglottis and is drooling A nurse is caring for a client who reports frequent headaches after taking chewable isosorbide dinitrate. Which of the following statements should the nurse include? ---------

• Correct Answer ----------- The headaches should decrease as you get used to the medication A nurse is implementing a bladder training program for client after she had a stroke. Which of the following interventions should the nurse take? ---------- Correct Answer ----- ------ Check for residual urine after voiding A nurse is contributing to the POC for a client who is pregnant and reports having trouble sleeping. Which of the following instructions should the nurse include in the POC? ---------- Correct Answer ----------- Lie in your left side with your top leg forward a nurse is reinforcing teaching w a client who has a prescription for amytriptyline. which of the following findings should the nurse include in the teaching as an adverse effect of this med? ---------- Correct Answer ----------- orthostatic hypotension a nurse is contributing to the poc of a client who has major depressive disorder. which of the following recommendations should the nurse include in the poc? ---------- Correct Answer ----------- encourage the client to use positive self talk a nurse is preparing to administer ibuprofen solution 60 mg orally to a 7 month old infant who is febrile. Available is ibuprofen 50 mg/1.25 mL. how many mL should the nurse administer? ---------- Correct Answer ----------- 1.5 mL a nurse is caring for a child who has terminated cancer. which of the following responses by the child's school-age brother should the nurse expect? ---------- Correct Answer ----------- believes his bad behavior is causing his brother's death A nurse is caring for a client who is experiencing alcohol withdrawal. which of the following medications should anticipate administering to prevent complications of withdrawal? ---------- Correct Answer ----------- Lorazepam A nurse is reinforcing dietary teaching w clients whose pregnancy BMI was 30.5. the nurse should recognize that the client understands the teaching when she states that she should expect to gain how many lbs during her pregnancy? ---------- Correct Answer ----------- 16 lb

a nurse is assisting w the care of a client following ect therapy for the treatment of depressive disorder. which of the following findings should the nurse expect 15 mins following this procedure? ---------- Correct Answer ----------- disorientation A nurse is caring for an adolescent who has bulimia nervosa. Which of the following actions should the nurse take first? ---------- Correct Answer ----------- Observe the client during and after meals A nurse is monitoring a client who is postop. Which of the following actions should the nurse take when collecting data about the client's respirations? ---------- Correct Answer ----------- Observe the movements of the client's chest wall A nurse is preparing to give a change o shift report on a client who is 2 days postop following a total knee arthroplasty. Which of the following info about the client should the nurse include in the report? ---------- Correct Answer ----------- Time of last pain medication A nurse is reinforcing d/c teaching w a client who has bipolar disorder and a new prescription for carbamazepine. Which of the following statements by the client indicates an understanding of the teaching? ---------- Correct Answer ----------- I will plan to avoid grapefruit juice while taking this medication An AP tells the charge nurse that her assignment is too demanding. She angrily tells the nurse to reassign one of her tasks to another AP. Which of the following actions should the nurse take to resolve the conflict? ---------- Correct Answer ----------- Ask the AP to discuss the issue in a private area A nurse is reinforcing teaching w a client who has arthritis. Which of the following instructions should the nurse include in the teaching? ---------- Correct Answer ----------- Engage in low-impact aerobic exercises A nurse is caring for a female client who has an indwelling catheter w a urinary drainage bag system. Which of the following actions should the nurse take? ---------- Correct Answer ----------- Secure the tubing w adhesive tape the lower abdomen a nurse is assisting w a support group for client who have experienced intimate partner violence. the nurse should identify which of the following client statements as indicating the greatest risk for violence? ---------- Correct Answer ----------- I have decided to tell my husband I'm leaving him a nurse is collecting data from a client who is receiving magnesium sulfate via continuous IV infusion for preterm labor. which of the following findings should the nurse expect? ---------- Correct Answer ----------- hypotension

a charge nurse working in a ltc facility overhears 2 aps in the nurses stations discussing a client who was just admitted. which of the following actions should the nurse take? ---- ------ Correct Answer ----------- tell the aps to stop the conversation a nurse is reinforcing teaching w a client who is scheduled for an intravenous pyelogram. which of the following statements made by the client indicates an understanding of the teaching? ---------- Correct Answer ----------- i will feel a warming sensation after the injection of the dye a nurse is assisting w the poc of a client who has end-stage amyotrophic lateral sclerosis and has developed pneumonia. which of the following actions should the nurse take? ---------- Correct Answer ----------- verify the status of the client's advanced directive a nurse is reinforcing teaching w a new mother facility safety measures. which of the following statements by the mother indicates an understanding of the teaching? ---------- Correct Answer ----------- i will have an identification band that matches the one that my baby wears a nurse is caring for a client who is 2 days postop following a total bilateral mastectomy. the client is tearful and looks away when her surgical dressings are removed. the nurse should place the priority action on which of the following actions? ---------- Correct Answer ----------- identifying the client's perception of the changes of her physical appearance a nurse is reinforcing teaching w a client who is at risk for hypertension. which of the following risk reduction strategies should the nurse include in the teaching? ---------- Correct Answer ----------- walk 30 mins 5 days per week a nurse is caring for a client who has dependent personality disorder. which of the following manifestations should the nurse expect? ---------- Correct Answer ----------- submissive a nurse is assisting w the admission of a client who has varicella zoster. which of the following interventions should the nurse plan to implement? ---------- Correct Answer ----- ------ initiate contact precautions for the client a nurse is planning to administer 4 different meds to a client via gtube. which of the following actions should the nurse take? ---------- Correct Answer ----------- allow separate meds to flow through the tube by gravity a nurse is preparing to administer medications to a client who has pneumonia and is on droplet precautions. which of the following supplies should the nurse use while caring for this client? ---------- Correct Answer ----------- surgical mask

a nurse is reinforcing dietary teaching with a client who is at risk for cardiovascular disease. which of the following statements by the client indicates an understanding of the teaching? ---------- Correct Answer ----------- i have unsalted pretzels for a snack a nurse in an inpatient psychiatric unit is caring for a client who was raised in an asian culture. which of the following communication techniques by the nurse demonstrates cultural sensitivity? ---------- Correct Answer ----------- holding eye contact for brief instances a nurse is reinforcing teaching about safe food handling w a client who is recovering from food poisoning. which of the following statements by the client indicates an understanding of the teaching? ---------- Correct Answer ----------- I will be sure to cook chicken to 180 degree fahrenheit a nurse is assisting w the d/c plan for a client who has burns on his arms and hands. which of the following referrals should the nurse recommend to improve the client's ADLs? ---------- Correct Answer ----------- occupational therapist a nurse is assisting w a prenatal exam of a client who is at 8 weeks gestation. the nurse notes that the client's vagina and vulva are a purplish color. the nurse should document this finding as which of the following? ---------- Correct Answer ----------- Chadwick's sign a nurse should recognize that a client's right of confidentiality has been breached when which of the following occur? ---------- Correct Answer ----------- a nurse tells the chaplain that her assigned client has a new diagnosis of cancer a nurse in a med surg unit is preparing to assist w the admission of clients who were injured in a tornado. which of the following clients should the nurse recommend for d/c to make room for the new admissions? ---------- Correct Answer ----------- a client who has had a radial mastectomy 36 hr ago and has a surgical drain a nurse is reviewing lab values for a client who is experiencing respiratory acidosis. which of the following ABG values should the nurse expect? ---------- Correct Answer ---- ------- pH 7. PaCO2 50 mm Hg a nurse is caring for a client who is receiving oxygen when a fire starts in an adjacent room (move steps in order) ---------- Correct Answer ----------- 1. move the client to a safe location

2. pull the nearest fire alarm
3. shut all the doors and windows
4. attempt to extinguish a nurse is caring for a client who's receiving morphine for pain. which of the following findings indicate that the client is experiencing an adverse effect of the medication? ----- ----- Correct Answer ----------- urinary retention

the nurse is reinforcing dietary teaching w a client who has cholecystitis. which of the following food choices should indicate that the client understands the teaching? ---------- Correct Answer ----------- skim milk a nurse is caring for a client who has a new mastectomy. which of the following statements by the client should indicate to the nurse that the client is beginning to cope w the changes in her body image? ---------- Correct Answer ----------- i am afraid to discuss my own concerns w my husband a nurse is caring for an older adult client who reports having trouble getting sleep at night. which of the following recommendations should the nurse make? ---------- Correct Answer ----------- establish daily exercise routine A nurse is caring for an adolescent that states, "I joined the track and field team, so I won't argue with my brothers anymore." The nurse should identify that the client is using which of the following defense mechanisms? ---------- Correct Answer ----------- sublimination a nurse is nurse is reinforcing teaching with a client who has a prescription for a transdermal nitroglycerin patch. which of the following statements by the client indicates an understanding of this medication? ---------- Correct Answer ----------- i will place the patch on a hairless area of skin A nurse is observing assistive personnel check the tympanic temperature. Which indication that the AP understands how to perform the procedure.

• The AP pulls the pinna up and back.
• The AP inserts the probe with a straight, forward motion.
• The AP points the probe posteriorly.
• The AP positioned the client facing her. ---------- Correct Answer --------- The AP pulls the pinna up and back. A nurse is assisting with the care of a client following electroconvulsive therapy for the use of the expected finding should the nurse expect 15 min following the procedure.?
• Paresthesia
• Tonic- clonic-seizures.
• Disorientation
• Sleep apnea ---------- Correct Answer --------- Disorientation A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation.

The nurse notes that the client's vagina and vulva purplish color. The nurse should docket this finding as which of the following?

• Ballottement
• Chadwick's sign
• Chloasma
• Hagar's sign ---------- Correct Answer --------- Chadwick's sign A nurse is assisting in providing postmortem care to a client who was a devout follower of Hinduism. Which of the following request should the nurse anticipate from the client's family?
• To bury the client's body within 24hr of their death.
• To cremate the client's body pg 25
• To stay with the client's body for 8hr following their death
• To prohibit medical personnel from touching the client's body ---------- Correct Answer - -------- To cremate the client's body pg 25 A nurse is reinforcing with a client who has a new diagnosis of COPD. Which of the following statements by the client indicates understanding of the teaching?
• I should practice pursed-lip breathing exercises.
• I should do aerobic exercises once per day.
• I will consume low protein, low calorie foods.
• I will increase my fluid intake to 1,700 milliliter per day. ---------- Correct Answer --------- I should practice pursed - lip breathing exercises. A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend including in the plan?
• Measure the client's abdominal girth daily.
• Restrict the client's sodium intake to 3 g per day.
• Keep the client's daily protein intake below o.8g/kg
• Position the client supine with legs elevated. ---------- Correct Answer --------- Measure the client's abdominal girth daily. A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?
• The client fell because the assistive personnel did not place non skid slippers on the client.
• Client stated, I lost my balance and fell when I got out of bed to go to the bathroom.
• An incident report has been completed and sent to risk management.

• The client does not appear to have any injuries resulting from the fall. ---------- Correct Answer --------- Client stated, I lost my balance and fell when I got out of bed to go to the bathroom. A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following should the nurse include?
• Use written signs to assist the client with locating the bathroom.
• Use confrontation to manage the client 's behavior.
• Limit the number of choices for the client.
• Provider a stimulating environment for the client. ---------- Correct Answer --------- Limit the number of choices for the client. A nurse overhears two assistive personnel AP in the nurse station discussing a client who was recently admitted. Which of them should the nurse take?
• Document the event in the client's progress notes.
• Tell the APs to stop the conversation.
• Submit an incident report to the risk manager.
• Inform the client of the APS actions. ---------- Correct Answer --------- Tell the APs to stop the conversation. A nurse is reinforcing discharge teaching with the caregiver of a client who has dependent personality disorder. Which of the following instructions should the nurse include in the teaching?
• Assume responsibility for making the client's decisions.
• Limit the client's social interactions
• Maintain a verbal no harm contract with the client.
• Encourage the client to be assertive. ---------- Correct Answer --------- Encourage the client to be assertive. A nurse is caring for a client who is 2 days postoperative following a total bilateral. mastectomy. The client is tearful and looks away when surgical dressing is removed. The nurse should place the priority on which of the following actions?
• Providing the client with information on community resources that will strengthen her coping skills.
• Encouraging the client to write about her feelings in a journal each day.
• Identify the client's perception of the changes in her physical appearance.
• Demonstrating a nonjudgmental attitude toward the client when providing care for her surgical wounds. ---------- Correct Answer --------- Identify the client's perception of the changes in her physical appearance.

A nurse working in a rehabilitation unit is administering medications to two clients who have the same name. Which of the following should the nurse use to verify the identities of each client?

• The names of the clients nearest relatives
• The telephone numbers of the clients.
• The room numbers of the clients
• The diagnoses of the clients ---------- Correct Answer --------- The telephone numbers of the clients. A nurse is reviewing the pain of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?
• Administration of an iron injection using Z- track technique.
• Placement of a central venous catheter.
• Insertion of a nasogastric tube.
• Irrigation of a wound with antibiotic solution. ---------- Correct Answer --------- Placement of a central venous catheter. A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?
• Administer aspirin if the client develops a fever.
• Assign the client to a negative pressure airflow room.
• Initiate contact precautions for the client.
• Have visitors remain at least 0.91 m (3feet) away from the client ---------- Correct Answer --------- Initiate contact precautions for the client. A nurse is reinforcing teaching with a client who has GERD and a prescription for pantoprazole. Which of the following statement indicate understanding of the teaching?
• I have to take this medication on an empty stomach.
• I will need to remain upright for 1 hour after taking the medication.
• I can take antacids at the same time as this medication.?
• I should expect to have diarrhea while taking this medication. ---------- Correct Answer - -------- I will need to remain upright for 1 hour after taking the medication. A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following should the nurse take?
• Hold gentle, direct pressure on the protruding organ.
• Place the client's knees in an extended position.
• Raise the head of the bed to a 45 angle.
• Cover the wound with sterile, saline- soaked gauze. ---------- Correct Answer --------- Cover the wound with sterile, saline- soaked gauze.

A nurse in a long term care facility is caring for a client who has methicillin - resistant Staphylococcus aureus MRSA. Which of the following actions should the nurse take?

• Restrict the client client's visitors.
• Remove personal protective equipment after leaving the client's room.
• Ensure that the negative air pressure is active for the client's room.
• Wear a gown when assisting the client with personal hygiene. ---------- Correct Answer --------- Wear a gown when assisting the client with personal hygiene. A nurse is administering pancrelipase to a child who a child who has cystic fibrosis. Which of the following outcomes should the nurse expectation effect of the treatment?
• Improved respiratory function.
• Improved absorption of vitamin B and C.
• Reduced fat in the stools.
• Decrease sodium excretion. ---------- Correct Answer --------- Reduced fat in the stools. A nurse is completing postmortem documentation for a client. Which of the following information should the nurse include in the documentation?
• Cause of the client's death.
• Location of the identification tag on the client's baby
• Copy of the client's advance directives.
• Last set of the client's vital signs. ---------- Correct Answer --------- Last set of the client's vital signs. A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has a history of dysphasia. Which of the following instruction should the nurse include in the teaching?
• Place oral suction equipment next to the client's bedside.
• Give the client a straw to use for drinking
• Provide thin liquids to help the client swallow
• Use a needless syringe to instill feedings. ---------- Correct Answer --------- Place oral suction equipment next to the client's bedside. A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg. 1 tablet every 3 to 4 hr PRN for pain inadvertently administer 2 tablets to the client. In which of the following locations should the nurse document this client care incident?
• Incident report
• Nursing care plan
• Controlled substance inventory record.
• Provider's progress notes ---------- Correct Answer --------- Controlled substance inventory record

A community health nurse is developing a brochure about hypertension. Which of the following actions should the nurse take? Use a 12- point front size Write the information at an 8th grade reading level. Present information from complex to simple. Explain medical terminology using basic, one - syllable words. ---------- Correct Answer -- ------- Explain medical terminology using basic, one - syllable words. A nurse is caring for a client who has end stage kidney disease. The client has decided to stop dialysis treatment. Which of the following actions should the nurse take? Tell the client she should discuss this decision with her family. Ask the facility chaplain to visit the client. Support the client's decision to stop the treatment. Discuss alternative treatment methods with the client. ---------- Correct Answer --------- Support the client's decision to stop the treatment. A nurse at a long-term care facility is part of a risk management team that is creating a plan to lower infection rates in the facility. Which of the following instructions regarding hand hygiene should the nurse include? Wash hands under running water for at least 10 seconds. Dry hands thoroughly from fingers to wrist. Clean hands with alcohol- based hand gel for 15 seconds. Hold the hands slightly higher than the elbows when using running water. ---------- Correct Answer --------- Hold the hands slightly higher than the elbows when using running water. A nurse is talking with a client who refuses a blood transfusion for religious reasons. Which of the following responses should the nurse make. I am sure that everything will be all right, regardless of your decision. Making this decision is wrong. If I were you, I would contact your spiritual director. You have a right to change your mind. ---------- Correct Answer --------- You have a right to change your mind. A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take? Instruct the client to hold the drainage bag at waist height when ambulating. Secure the tubing with adhesive tape to the lower abdomen. Coil the tubing on the bed above collection bag.

Collect a sterile specimen from the urinary drainage bag. ---------- Correct Answer --------

• Instruct the client to hold the drainage bag at waist height when ambulating. A nurse is reinforcing discharge teaching with a client who states. I don't feel confident driving to my follow- up appointment. The nurse obtain a referral for which of the following members of the health care team? Physical thermal therapist Occupational therapist Social worker Primary care provider ---------- Correct Answer --------- Occupational therapist A nurse is reinforcing teaching about hand hygiene with newly licensed nurses. Which of the following information should the by included in the teaching? Interlace the finger while rubbing hands together. Dry hands starting from arms to fingers. Apply friction to hands for 10 seconds. Use hot water to wash hands. ---------- Correct Answer --------- Interlace the finger while rubbing hands together. A nurse is contributing to the plan of care for a client who had prolonged exposure to cold weather and has a core body temperature of 32.5 C (90.5 F). Which of the following data is the priority for the nurse to monitor? Muscle strength Pain sensation Heart rhythm Urinary output ---------- Correct Answer --------- Heart rhythm A nurse is caring for a client who has Clostridium difficile. When applying a cover gown, which of the following techniques should the nurse do? Tie the gown with the gloves on. Push the gown sleeves up to the elbows. Apply the gown before the gloves. Tuck the glove cuffs under the gown sleeves. ---------- Correct Answer --------- Apply the gown before the gloves. A nurse enters the room of a school- age and finds them on the floor experiencing a tonic - clonic. Which of the following actions should the nurse take? Turn the child onto their back. Place a pillow under the child's head. Restrain the child's upper extremities.

Place a padded tongue blade in the child's mouth. ---------- Correct Answer --------- Place a pillow under the child's head. A nurse is preparing to give change of shift report on a client who is 2 day postoperative following a total knee arthroscopy. Which of the following information should the nurse include in the report? Time of the last pain medication Admission vital signs Steps required for dressing change. Preferred bath time. ---------- Correct Answer --------- Time of the last pain medication A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers. Which should the nurse include? Corn Potatoes Grapes Oranges ---------- Correct Answer --------- Grapes A nurse is reinforcing teaching with a # parent of a child who has ADHD and is taking methylphenidate which of the following statements by the parents indicated the medication is effective ---------- Correct Answer --------- our child is able to complete his homework on time A nurse is reinforcing teaching with a client who has primary open angle glaucoma and a new prescription for timolol eye drops. which of the following statements by the client indicates an understanding of the teaching ---------- Correct Answer --------- I should check my heart rate while taking this medication A nurse is assisting in the care of a client who is at 34 weeks of gestation and is experiencing lower back pain. which of the following recommendations should the nurse make? ---------- Correct Answer --------- perform pelvic rocking exercises several times per day A nurse is collecting data from a client who diabetic ketoaçidosis. Which of the following findings should the nurse expect? ---------- Correct Answer --------- fruity breath A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy the nurse should explain to the client that which of the following adverse reactions can occur following the procedure ---------- Correct Answer --------- temporary memory loss A nurse is caring for a client who has anorexia nervosa and who has a behavioral management plan in place. which of the following findings should the nurse identify as an indication that the plan is effective ---------- Correct Answer --------- potassium 3.5/g dl