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A T I PN COMPREHENSIVE PREDICTOR 2020 FORM C /PN ATI COMPREHENSIVE PREDICTOR 2019 REAL E, Exams of Nursing

A T I PN COMPREHENSIVE PREDICTOR 2020 FORM C /PN ATI COMPREHENSIVE PREDICTOR 2019 REAL EXAM 180 QUESTIONS AND CORRECT ANSWERS| GRADED A+ | GUARANTEED PASS

Typology: Exams

2023/2024

Available from 12/17/2024

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Download A T I PN COMPREHENSIVE PREDICTOR 2020 FORM C /PN ATI COMPREHENSIVE PREDICTOR 2019 REAL E and more Exams Nursing in PDF only on Docsity!

A T I PN COMPREHENSIVE PREDICTOR 2020 FORM

C /PN ATI COMPREHENSIVE PREDICTOR 2019 REAL

EXAM 180 QUESTIONS AND CORRECT ANSWERS|

GRADED A+ | GUARANTEED PASS

A nurse is developing an in service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? A. The clients exhibits impulse behavior B. The client might act seductively C. The client is exceptionally clingy to others D. The client is overly concerned about minor details - ANSWER A. The clients exhibits impulse behavior A nurse in a clinic is assessing a client who has sinusitis. Which of the following techniques should the nurse use to identify manifestations of this disorder? A. Percussion of posterior lobes of lungs B. Auscultation of the trachea C. Inspection of the conjunctiva D. Palpation of the orbital areas - ANSWER D. Palpation of the orbital areas Intra-dermal Injections areas. A. Buttocks B. Upper back C. Hamstring - ANSWER B. Upper back A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following are expected findings? SATA A. Impulse control difficulty

B. Left Hemiplegia C. Loss of depth perception D. Aphasia E. Lack of situational awareness - ANSWER A. Impulse control difficulty B. Left Hemiplegia C. Loss of depth perception E. Lack of situational awareness A nurse is caring for a client who has global aphasia (both receptive and expressive.). Which of the following should the nurse include in the client's plan of care? SATA A. Speak to the client at a slower rate B. Assist the client to use flash card with pictures C. Speak to the client in a loud voice. D. Complete sentences that the client cannot finish. E. Give instructions one step at a time - ANSWER A. Speak to the client at a slower rate B. Assist the client to use flash card with pictures E. Give instructions one step at a time A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding? A. Impulse control difficulty B. Poor judgement C. Inability to recognize familiar objects D. Loss of depth perception - ANSWER C. Inability to recognize familiar objects A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.47, PaCo2 32 mm Hg. HCO3 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid-base imbalances? A. Respiratory acidosis B. Respiratory alkalosis

C. Metabolic acidosis D. Metabolic alkalosis - ANSWER B. Respiratory alkalosis A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications? SATA A. Dyspnea B. Localized bloody drainage on the dressing C. Fever D. Hypotension E. Report of pain at the puncture site - ANSWER A. Dyspnea C. Fever D. Hypotension A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client's room? SATA A. Oxygen B. Sterile water C. Enclosed hemostat clamps D. Indwelling urinary catheter E. Occlusive dressing - ANSWER A. Oxygen B. Sterile water C. Enclosed hemostat clamps E. Occlusive dressing A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? SATA A. Gentle Constant bubbling in the suction control chamber B. Rise and fall in the level of water in the water seal chamber with inspiration and expiration C. Exposed sutures without dressing.

D. Drainage system upright at chest level - ANSWER A. Gentle Constant bubbling in the suction control chamber B. Rise and fall in the level of water in the water seal chamber with inspiration and expiration A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine? A. HR 58 B. Fasting blood glucose 100 C. Hgb 14 D. WBC 2900 - ANSWER D. WBC 2900 A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? SATA A. Encourage the client to cough every 2 hours B. Check the continuous bubbling in th suction chamber C. Strip the drainage tubing every 4 hours. D. Clamp the tube once a day. E. Obtain a chest x-ray - ANSWER A. Encourage the client to cough every 2 hours B. Check the continuous bubbling in th suction chamber E. Obtain a chest x-ray A nurse is orientation a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates and understanding of PSV? A. "It keeps the alveoli open and prevents atelectasis." B. "It allows preset pressure delivered during spontaneous ventilation." C. "It guarantees minimal minute ventilator. D. "It delivers a preset ventilatory rate and tidal volume to the client." - ANSWER B. "It allows preset pressure delivered during spontaneous ventilation."

A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? SATA A. Confusion B. Pale skin C. Bradycardia D. Hypotension E. Elevation blood pressure. - ANSWER B. Pale skin E. Elevation blood pressure. A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching? A. Apply a vest restraint if self-extubation is attempted. B. Monitor ventilator settings ever 8 hours. C. Document tube placement in centimeters at the angle of jaw. D. Assess breath sounds every 1 to 2 hours. - ANSWER D. Assess breath sounds every 1 to 2 hours. A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? A. Non rebreather mask B. Venturi mask C. Nasal cannula D. Simple face mask - ANSWER B. Venturi mask A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following modes of ventilation that increase the effort of the client's respiratory muscles should the nurse include in the plan of care? SATA A. Assist-control B. SIMV C. CPAP D. PSV

E. Independent lung ventilation - ANSWER B. SIMV C. CPAP D. PSV A nurse is caring for a client who has pneumonia. Assessment findings include temperature 37.8 C ( F), respirations 30/min, blood pressure 130/76, heart rate 100/min, and SaO2 91% on room air. Prioritize the following nursing interventions. A. Administer antibiotics. B. Administer oxygen therapy. C. Perform a sputum culture. D. Administer an antipyretic medication to promote client comfort. - ANSWER B. Administer oxygen therapy. C. Perform a sputum culture. A. Administer antibiotics. D. Administer an antipyretic medication to promote client comfort. A nurse in the emergency department is caring for a client who is having an acute asthma attack. Which of the following assessments indicates that the respiratory status is declining? SATA A. SaO2 95% B. Wheezing C. Retraction of sternal muscles D. Pink mucous membranes E. Premature ventricular complexes (PVC's) - ANSWER B. Wheezing C. Retraction of sternal muscles E. Premature ventricular complexes (PVC's) A nurse is caring for a client 2 hours after admission. The client has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medication should the nurse expect to administer? A. Antibiotic B. Beta-blocker

C Antiviral D. Beta2 agonist - ANSWER D. Beta2 agonist A nurse is providing discharge teaching to a client who has a new prescription for prednisone for asthma. Which of the following client statements indicates an understanding in teaching? A. "I will decrease my fluid intake while taking this medication." B. "I will expected to have black, tarry stools." C. "I will take my medication with meals." D. "I will monitor for weight loss while on this medication." - ANSWER C. "I will take my medication with meals." A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following client statements indicates an understanding of the teaching? A. "This medication can decrease my immune response." B. "I take this medication to prevent asthma attacks." C. "I need to take this medication with food." D. "This medication has a slow onset to treat my symptoms." - ANSWER B. "I take this medication to prevent asthma attacks." A nurse is preparing to administer a dose of a new prescription of prednisone to a client who has COPD. The nurse should monitor for which of the following adverse effects of this medication?SATA A. Hypokalemia B. Tachycardia C. Fluid retention D. Nausea E. Black, tarry stools - ANSWER A. Hypokalemia C. Fluid retention E. Black, tarry stools A home health nurse is teaching a client who has active tuberculosis. The provider has prescribed the following medication regimen: isoniazid 250 mg PO daily, rifampin 500 mg PO daily, pyrazinamide 750

mg PO daily, and ethambutol 1 mg PO daily. Which of the following client statements indicate the client understands the teaching? SATA A. "I can substitute one medication for another if I run out because that all fight infection." B. I will wash my hands each time I cough C. I will wear a mask when I am in a public area D."I am glad I don't have to have any more sputum specimens." E. "I don't need to worry where I go once I start taking my medications." - ANSWER B. I will wash my hands each time I cough C. I will wear a mask when I am in a public area .A nurse is teaching a client who has tuberculosis. Which of the following statements should the nurse include in the teaching? A. "You will need to continue to take the multi-medication regimen for 4 months." B. You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication C. "You will need to remain hospitalized for treatment." D. "You will need to wear a mask at all times." - ANSWER B. You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a multi-medication regimen. Which of the following instructions should the nurse give the client related to ethambutol? A. "Your urine can turn a dark orange." B. "Watch for a change in the sclera of your eyes." C. "Watch for any changes in vision." D. "Take vitamin B6 daily." - ANSWER C. "Watch for any changes in vision." A nurse is preparing to administer a new prescription for isoniazid (INH) to a client who has tuberculosis. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication? A. "You might notice yellowing of your skin." B. "You might experience pain in your joints."

C. "You might notice tingling of your hands." D. "You might experience loss of appetite." - ANSWER C. "You might notice tingling of your hands." A nurse is providing information about tuberculosis to a group of clients at a local community center. Which of the following manifestations should the nurse include in the teaching? (Select all that apply.) A. Persistent cough B. Weight gain C. Fatigue D. Night sweats E. Purulent sputum - ANSWER A. Persistent cough C. Fatigue D. Night sweats E. Purulent sputum A nurse is caring for a group of clients. Which of the following clients are at risk for pulmonary embolism? SATA A. A client who has a BMI of 30 B. A female client who is postmenopausal C. A client who has a fractured femur D. A client who is a marathon runner E. A client who has chronic a fib - ANSWER A. A client who has a BMI of 30 C. A client who has a fractured femur E. A client who has chronic a fib A nurse is assessing a client who has a pulmonary embolism. Which of the following information should the nurse expect to find? SATA A. Bradypnea. B. Pleural friction rub C. Hypertension D. Petechiae

E. Tachycardia - ANSWER B. Pleural friction rub D. Petechiae E. Tachycardia A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states she is anxious and is unable to get enough air. Vital signs are HR 117/min, respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. Which of the following nursing actions is the priority? A. Notify the provider. B. Administer heparin via IV infusion. C. Administer oxygen therapy. D. Obtain a spiral CT scan. - ANSWER C. Administer oxygen therapy. A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate and immediate concern for the nurse? A. "I am allergic to morphine." B. "I take antacids several times a day." C. "I had a blood clot in my leg several years ago." D. "It hurts to take a deep breath." - ANSWER B. "I take antacids several times a day." A nurse is caring for a client who is to receive thrombolytic therapy. Which of the following factors should the nurse recognize as a contraindication to the therapy? A. Hip arthroplasty 2 weeks ago B. Elevated sedimentation rate C. Incident of exercise-induced asthma D. 1 week ago Elevated platelet count - ANSWER A. Hip arthroplasty 2 weeks ago A nurse is assessing a client following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? SATA A. Tachypnea B. Deviation of the trachea

C. Bradycardia D. Decreased use of accessory muscles E. Pleuritic pain - ANSWER A. Tachypnea B. Deviation of the trachea E. Pleuritic pain A nurse is reviewing the prescriptions for a client who has a pneumothorax. Which of the following actions should the nurse perform first? A. Assess the client's pain. B. Obtain a large-bore IV needle for decompression. C. Administer lorazepam. D. Prepare for chest tube insertion. - ANSWER B. Obtain a large-bore IV needle for decompression. A nurse is reviewing discharge instructions for a client who experienced a pneumothorax. Which for the following statement should the nurse use when teaching the client? A. "Notify the provider if you experience weakness." B. "You should be able to return to work in 1 week." C. "You need to wear a mask when in crowded areas." D. "Notify your provider if you experience a productive cough." - ANSWER D. "Notify your provider if you experience a productive cough." A nurse in the emergency department is assessing a client who has a suspected flail chest. Which of the following findings should the nurse expect? (Select all that apply.) A. Bradycardia B. Cyanosis C. Hypotension D. Dyspnea E. Paradoxic chest movement - ANSWER B. Cyanosis C. Hypotension D. Dyspnea

E. Paradoxic chest movement A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6 C (101.4 F), and SaO2 92% on room air. Which of the following actions should the nurse take first? A. Obtain a chest ex-ray. B. Prepare for chest tube insertion. C. Administer oxygen via high-flow mask. D. Initiate IV access. - ANSWER C. Administer oxygen via high-flow mask. A nurse is orientation a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A. "This medication is given to treat infection." B. "This medication is given to facilitate ventilation." C. "This medication is given to decrease inflammation." D. "This medication is given to reduce anxiety." - ANSWER B. "This medication is given to facilitate ventilation." A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome? SATA A. A client who experienced a near-drowning incident B. A client following coronary artery bypass graft surgery C. A client who has a Hg 15. D. A client who has dysphagia E. A client who experienced a drug overdose - ANSWER A. A client who experienced a near-drowning incident B. A client following coronary artery bypass graft surgery D. A client who has dysphagia E. A client who experienced a drug overdose

A nurse is planning care for a client who has severe respiratory distress system (SARS). Which of the following actions should be included in the plan of care for this client? SATA A. Administer antibiotics. B. Provide O C. Administer bronchodilators. D. Administer antiviral meds E. Maintain ventilatory support. - ANSWER B. Provide O C. Administer bronchodilators. E. Maintain ventilatory support. A nurse is caring for a client who is receiving vecuronium for acute respiratory distress syndrome. Which of the following medications should the nurse anticipate administering with this medication? SATA A. Fentanyl B. Furosemide C. Midazolam D. Famotidine E> Dexamethasone - ANSWER A. Fentanyl C. Midazolam A nurse is orienting a newly licensed nurse on the care of a client who is to have a line placed for hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates effectiveness of the teaching? A. "Air should be instilled into the monitoring system prior to the procedure." B. "The client should be positioned on the left side during the procedure." C. "The transducer should be level with the second intercostal spaced after the line is placed." D. "A chest x-ray is needed to verify placement after the procedure." - ANSWER D. "A chest x-ray is needed to verify placement after the procedure." A nursing planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include?

A. Offer small amounts of clear liquids 6 hr following surgery (assess for gag reflex first) B. Give cromolyn nebulizer solution every 6 hr (for asthma) C. Apply a warm compress to the operative site every 4 hr D. Administer analgesics on a scheduled basis for the first 24 hr - ANSWER D. Administer analgesics on a scheduled basis for the first 24 hr A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take first? A. Shave hairy areas of skin prior to application ( apply to hairless, clean & dry areas to promote absorption; avoid oily or broken skin) B. Wear gloves to apply the patch to the client's skin C. Apply the patch within 1 hr of removing it from the protective pouch (apply immediately) D. Remove the previous patch and place it in a tissue (fold patch in half with sticky sides pressed together) - ANSWER B. Wear gloves to apply the patch to the client's skin A nurse is reviewing the laboratory results for a client who has Cushing's disease. The nurse should expect the client to have an increase in which of the following laboratory values? A. Serum glucose level- increased B. Serum Ca level decreased C. Lymphocyte count decreased D. Potassium decreased - ANSWER A. Serum glucose level- increased A nurse is caring for a client who has severe pre eclampsia and is receiving mg sulfate IV. The nurse discontinues the magnesium sulfate after the client displaces toxicity. Which of the following actions should the nurse take? A. Position the client supine B. Prepare an IV bolus of destrose 5% in water C. Administer methy lergonovine IM D. Administer Ca gluconate IV - ANSWER D. Administer Ca gluconate IV

A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field? A. Place the cap from the solution sterile side up on clean surfaces B. Open the outermost flap of the sterile kit toward the body→ flap AWAY from the body's first C. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field → 2.5 cm (1-inch) border around any sterile drape or wrap that is considered contaminated. D. Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW waist level; should be ABOVE waist level - ANSWER A. Place the cap from the solution sterile side up on clean surfaces A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which action should the nurse take first? A. Educate the client about medical Dx B. Refer the client to a meal delivery program C. Identify environmental hazards at home D. Arrange a client for transportation - ANSWER C. Identify environmental hazards at home A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching A. HbA1c level greater than 8%- 6.5 - 8 is the target reference. B. Blood glucose level greater than 200 mg/dL at bedtime C. Blood glucose level less than 60 mg/dL before breakfast- < 70 = HYPOGLYCEMIC D. HbA1c level less than 7% - ANSWER D. HbA1c level less than 7% A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination? A. The client is experiencing an adverse reaction to rifampin B. Te client is showing evidence of phenytoin toxicity C. The client's seizure disorder is no longer under control - ANSWER B. Te client is showing evidence of phenytoin toxicity

A nurse is caring for a client who is 1 hr post op following rhinoplasty. which of the following requires immediate action? A. Increase frequency of swallowing B. Moderate sanguineous drainage on the drip pad C. Bruising to the face D. Absent gag reflex - ANSWER A. Increase frequency of swallowing A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease. Which of the following interventions should the nurse include in the plan of care? A. Give scheduled doses of acetaminophen every 6 hr B. Monitor the child cardiac status C. Administer antibiotics via intermittent IV bolus for 24 hr D. Provide stimulation with children of the same age in the playroom - ANSWER B. Monitor the child cardiac status A nurse is planning an educational program for high school students about cigarette smoking. Which of the following potential consequences of smoking is most likely to discourage adolescents from using tobacco? A. Use of tobacco might lead to alcohol and drug abuse B. Smoking in adolescence increases the risk of developing lung cancer later in life C. Use of tobacco decreases the level of athletic ability - ANSWER C. Use of tobacco decreases the level of athletic ability A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client? A. Total bilirubin B. Urine ketones C. Serum potassium - ANSWER C. Serum potassium (diuretics that restrain K= hyperkalemia risk) A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role? A. "I will let the client know that I am available as the interpreter."

B. "I will receive a small fee for interpreting for this client." C. "I am glad I'm available today, but when I'm not, you can use a family member." - ANSWER A. "I will let the client know that I am available as the interpreter." A nurse is providing discharge instructions to a client who has a new prescription for haloperidol which of the following adverse effects should the nurse instruct the client to report to the provider? A. Weight gain B. Dry mouth→ anticholinergic effects C. sedation s/s neuroleptic malignant syndrome??>> life threatening Sedation D. Shuffling gait→A/E EPS: is an indication of parkinsonism and should be reported - ANSWER D. Shuffling gait→A/E EPS: is an indication of parkinsonism and should be reported A nurse is teaching dietary guidelines to a client who has celiac disease which of the following food choices is appropriate for the client? A. White flour tortillas B. Potato pancakes C. Wheat crackers D. Canned barley soup - ANSWER B. Potato pancakes A nurse is working in acute care mental health facility is assessing a client who has schizophrenia. Which of the following findings should the nurse expect? A. All or nothing thinking B. Euphoric mood C. Disorganized speech - ANSWER C. Disorganized speech A nurse is caring for a client who is immobile which of the following interventions is appropriate to prevent contracture? A. Align a trochanter wedge between the clients legs B. Place a towel roll under the clients neck C. Apply an orthotic to the clients foot - ANSWER C. Apply an orthotic to the clients foot

A public health nurse working in a rural area is developing a program to improve health for the local population. Which of the following actions should the nurse plan to take? A. Provide anticipatory guidance classes to parents through public schools B. Have a nurse from the outside the community provide health lectures at the county hospital C. Encourage rural residents to focus health spending on tertiary health interventions D. Launch a media campaign to increase awareness about industrial pollution - ANSWER A. Provide anticipatory guidance classes to parents through public schools A nurse is preparing a change of shift report for an adult female client who is postoperative. Which of the following client information should the nurse include in the report? A. Hgb 12.8 g/dl - 12 - 16 B. Potassium 4.2 meq/l 3.5 - 5.0 meq C. RBC 4.4 million/mm D. Plateles 100,000 mm3 - ANSWER D. Plateles 100,000 mm A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the postpartum unit due to a staffing shortage for the shift. Which of the following client assignments should the nurse delegate to the LPN? A. A client post op following a bowel resection with an NGT set to suction B. A client who has fractured a femur yesterday and is expecting SOB C. A client who sustained a concussion and has unequal pupils D. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs - ANSWER A. A client post op following a bowel resection with an NGT set to suction A nurse is caring for a client who is at 41 week of gestation and is receiving oxytocin for labor induction. The nurse notes early deceleration on the fetal heart rate monitor. What should the nurse do? A. Continue to monitor HR B. Stop infusion C. Perform vaginal examination - ANSWER A. Continue to monitor HR

A nurse is conducting an initial assessment of a client and noticed a discrepancy between the clients current IV infusion and the information received during the shift report. Which of the following actions should the nurse take? A. Complete an incident report and place it in the client's medical record B. Compare the current infusion with the prescription in the client's medication record. C. Submit a written warning for the nurse involved in the incident. - ANSWER B. Compare the current infusion with the prescription in the client's medication record. A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine? A. WBC count 2,900 /mm B. FAsting blood glucose 100 mg/dl C. Hgb 14 g/Dl D. Heart rate 58/min - ANSWER A. WBC count 2,900 /mm A nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis C. The client asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate? A. You may breastfeed unless your nipples are cracked or bleeding. B. You must use a breast pump to provide breast milk. C. You must use nipple shield when breastfeeding. - ANSWER A. You may breastfeed unless your nipples are cracked or bleeding. A nurse is caring for a client who has returned to the medical-surgical unit following a transurethral resection of the prostate. Which of the following should the nurse identify as priority nursing assessment after reviewing the clients information? A. Level of consciousness B. Skin turgor C. Bowel Sounds - ANSWER A. Level of consciousness A nurse is caring for a client who has hyperthermia .Which of the following actions for the nurse to take?

A. Submerge the adolescent feet in ice water B. Cover the adolescent with a the C. Initiate seizure precautions - ANSWER C. Initiate seizure precautions A nurse in emergency department is caring for a client who has full thickness burn of the thorax and upper torso. After securing the client's airway, which of the following is the nurse's priority intervention? A. Providing pain management B. Offering emotional support C. Initiating IV fluid resuscitation - ANSWER C. Initiating IV fluid resuscitation A nurse is caring for a client who has cancer and is being transferred to hospice care. The client's daughter tells the nurse, "I'm not sure what to say to my mom if she asks me about dying." which of the following responses by the nurse is appropriate? (SATA) A.Hospice will take good care of your mom, so I wouldn't worry about that. B. Let's talk about your mom's cancer and how things will progress from here. C. Tell me how you are feeling about your mom dying. D. You sound like you have questions about your mom dying. Let's talk about it. - ANSWER B. Let's talk about your mom's cancer and how things will progress from here. C. Tell me how you are feeling about your mom dying. D. You sound like you have questions about your mom dying. Let's talk about it. A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings follow up care? A. A client who is taking bumetanide and has potassium level of 3.6 mEq/L (normal) B. A client who is scheduled for colonoscopy and taking sodium phosphate C. A client who received a Mantoux test 48 hours ago and has induration - ANSWER C. A client who received a Mantoux test 48 hours ago and has induration A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first? A. Clarify the source of the referral

B. Implement the nursing process C. Schedule a time for the home visit D. Contact the family by phone - ANSWER A. Clarify the source of the referral A nurse is discussing a weight loss with a client who is concerned about losing 6.8 kg (15lb) from an original weight of 9o.7 (200 lb). The nurse should identify the weight of the following total percentage? A. 7.5% B. 15% C. 8.1% D. 13.3% - ANSWER A. 7.5% A nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate. Which of the following interventions should the nurse implement? A.Perform fundal massage B. Pour water from a squeeze bottle over the client's perineal area. C. Insert an indwelling urinary catheter. - ANSWER B. Pour water from a squeeze bottle over the client's perineal area. A nurse is providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg /hr transdermal patch. Which of the following instructions should the nurse include in the teaching? A. Avoid hot tub while wearing the patch B. Apply patch to your forearm C. Avoid high-fiber foods while taking this medication - ANSWER A. Avoid hot tub while wearing the patch A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of non-blanchable erythema over his ischium. A. Teach the client to shift his weight every 15 min while sitting B. Place the client upright on a donut-shaped cushion - ANSWER A. Teach the client to shift his weight every 15 min while sitting

A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect? A. Heightened perceptual field B. Rapid speech - severe C. Feelings of dread - ANSWER A. Heightened perceptual field A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic?SATA A. Tremors B. Diaphoresis C. Acetone breath = DKA D. Polydipsia= Hyperglycemia E. Inability to concentrate - ANSWER A. Tremors B. Diaphoresis E. Inability to concentrate A community health nurse is planning primary prevention activities to reduce the occurrence of abuse. Which of the following strategies should the nurse include in the plan? A. Instruct healthcare professionals to identify abusive situations B. Locate financial support to open a shelter for abuse survivors C. Teach parenting skills to families at risk for abuse - ANSWER C. Teach parenting skills to families at risk for abuse A nurse and an assistive personnel (AP) are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the AP? A. Documenting the report of pain for a client who is postoperative B. Administering oral fluids to a client who has dysphagia C. Applying a condom catheter for a client who has spinal cord injury - ANSWER C. Applying a condom catheter for a client who has spinal cord injury

A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse? A. Offer the client saltine crackers between meals Suggest rinsing his mouth with an alcohol-based mouthwash Provide humidification of the room air Instruct the client on the use of esophageal speech - ANSWER A. Offer the client saltine crackers between meals A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel? A. Assess effectiveness of antiemetic medication- B. Perform chest compressions during cardiac resuscitation C. Perform a dressing change for a new amputee- D. Apply a transdermal nicotine patch- - ANSWER B. Perform chest compressions during cardiac resuscitation A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication for using lavender? A. The client takes vitamin C daily B. The client has a history of alcohol use disorder C. The client has a history of asthma D. The client takes furosemide twice daily - ANSWER C. The client has a history of asthma A nurse is caring for a client who has major depressive disorder and a new prescription for amitriptyline. The nurse should monitor for which of the following adverse effects? A. Increased salivation B. Urinary retention C. Weight loss - ANSWER B. Urinary retention A nurse is conducting a health promotion class about the use of oral contraceptives. Which of the following disorders is a contraindication for oral contraceptive use?

A. Asthma B. Hypertension C. Fibromyalgia D. Fibrocystic breast condition - ANSWER B. Hypertension A nurse is preparing to witness a client's signature on a consent form for a colon resection. The nurse should recognize that which of the following information should be provided to the client by the provider before signing the form? (SATA) A. Explain the procedure B. Expected outcome of the procedure C. Potential complications D. Possible alternative treatments E. Cost of the procedure - ANSWER A. Explain the procedure B. Expected outcome of the procedure C. Potential complications D. Possible alternative treatments A nurse is providing teaching to a client who will undergo a magnetic resonance imaging (MRI) scan. Which of the following statements is appropriate to include in the teaching? A. You should not have this procedure if you are allergic to iodine." B. You should not have this procedure if you have a tattoo." C. "The nurse will ask you to wear protective eyewear during this procedure." D. "The nurse will ask you to remove any transdermal patches prior to the procedure." - ANSWER A. You should not have this procedure if you are allergic to iodine." A nurse is caring for a child who has sickle cell anemia and experiencing vaso-constrictive crisis. Which of the following actions should the nurse include in the plan of care? A. Initiate IV fluid replacement B. Start a 24 hour urine collection C. Give aspirin

D. encourage ambulation - ANSWER A. Initiate IV fluid replacement A nurse is caring for a client who is dissatisfied with the care from the provider and decides to leave the facility against medical advice. After notifying the provider, which of the following actions is appropriate for the nurse to take? A. Summon a security guard B. Explain the risks of leaving C. Complete an incident report - ANSWER B. Explain the risks of leaving A nurse is making an initial postpartum home visit. Which of the following client statements should the nurse identify as a manifestation of increased risk for child abuse? A. "I try to respond to the baby quickly ." B. I think the baby should be sleeping through the night by now C. "I have several friends who come by to help out with the baby." - ANSWER B. I think the baby should be sleeping through the night by now A nurse is caring for an infant who has gastroenteritis. Which of the following assessments should the nurse report to the provider? A. Temperature 38 C(100.4 F) and pulse rate 124/min p B. Decreased appetite and irritability C. Pale and 24-hour fluid deficit of 30 mL D. Sunken fontanels and dry mucous membranes - ANSWER D. Sunken fontanels and dry mucous membranes A nurse is caring for a client who has pernicious anemia, Which of the following laboratory values should the nurse evaluate effectiveness of the treatment? A. Folate levelB. B. INR level C. Vitamin b12 level D. Creatinine level - ANSWER C. Vitamin b12 level