Ati RN Vati Comprehensive Predictor Form A ATI RN VATI Comprehensive Predictor Form B Ques, Exams of Nursing

Download Ati RN Vati Comprehensive Predictor Form A ATI RN VATI Comprehensive Predictor Form B Ques and more Exams Nursing in PDF only on Docsity! Ati RN Vati Comprehensive Predictor Form A ATI RN VATI Comprehensive Predictor Form B Questions With Correct Answers Latest Updated 2024/2025 A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect? - Correct Answer bounding pulse/generalized edema A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique - Correct Answera. This technique decreases the risk of subcutaneous infiltration 1. A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? - Correct Answera. Monitor the client for 1 hr after meals A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket. After moving the client to safety, which of the followings is the priority action? - Correct Answera. Close the fire door on the unit A nurse is assessing a client who has delirium due to a febrile illness. Which of the following findings should the nurse expect? - Correct Answera. Hallucinations 1. A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing? - Correct Answerhyperemesis 1. A home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The nurse should evaluate which of the following laboratory tests to determine effective long-term management of blood glucose levels? - Correct AnswerA1C 1. A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client? - Correct Answera. Use a dedicated stethoscope 1. A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take? - Correct AnswerTell the client to avoid drinking fluids 1 hr before bedtime 1. A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include? - Correct Answera. Place the newborn 45 cm from the light source 1. A nurse is planning care for a client who has schizophrenia and is having difficulty expressing their feelings. Which of the following referrals should the nurse make? - Correct Answersocial worker 1. A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication - Correct Answerdecreased reflexes 1. At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first? - Correct Answerindigestion 1. A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following actions by the assistive personnel requires the nurse to intervene? - Correct Answeroffer oral fluids to the client 1. A nurse on a medical unit has just received change-of-shift report. Which of the following clients should the nurse assess first? - Correct Answera. A 68 year old client who had a myocardial infarction 2 days ago and reports chest pain as a 4 on a scale of 0 to 10 1. A nurse is assessing a client prior to performing a blood draw. The nurse should identify that an allergy to which of the following food can indicate that the client has an allergy to latex? - Correct Answeravocados 1. A nurse is preparing to witness a client's signature on an informed consent for a total knee arthroplasty. Which of the following client statements indicates the nurse should contact the surgeon? - Correct Answera. I am thankful there are no serious complications from this type of surgery 1. A nurse is admitting a client who has antisocial personality disorder. Which of the following client behaviors should the nurse identify as consistent with this disorder? - Correct Answera. Uses others for personal gain 1. A nurse is teaching the parent of a school-age child who has scabies about the application of permethrin 5% cream. The nurse should include which of the following as a potential adverse effect of the medication? - Correct Answerburning the teaching? - Correct Answera. Allow the infant to suck on a pacifier during feedings 1. A charge nurse is creating assignments for the next shift for several nurses and one of the nurses is pregnant. Which of the following clients should the charge nurse assign to a nurse who is not pregnant? - Correct Answera. A 60 year old client who is recovering from shingles 1. A nurse is assessing a client who has a magnesium level of 4.4 mEq/L. Which of the following findings should the nurse expect? - Correct Answera. Hypotension 1. A nurse is reviewing the medical record of a client who has a new prescription for gentamicin. The nurse should identify that concurrent use with which of the following current medications can increase the client's risk for ototoxicity? - Correct Answera. Furosemide 1. A nurse is performing triage following a natural disaster. Which of the following clients should the nurse identify as the highest priority to receive care? - Correct Answera. A client who has a traumatic arm amputation 1. A nurse is assessing a client who is gravida 2, para 1. The client is at 41 weeks of gestation and is receiving oxytocin for the augmentation of labor. The nurse should decrease the infusion rate for which of the following findings? - Correct Answera. Contractions occur every 90 seocnds 1. A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood pressure. The nurse should identify that these findings are potential manifestations of which of the following? - Correct Answera. Opioid intoxication 1. A nurse is precepting a nursing student who brings the following client observations to the nurse's attention. Which of the following clients should the nurse assess first? - Correct Answera. A client who is coughing up pink-tinged sputum following a bronchoscopy and lung biopsy 1 hr ago 1. A nurse manager is reviewing documentation standards with a group of newly licensed nurses. Which of the following statements should the nurse manager include in the teaching? - Correct Answera. Include the complete name of the medication morphine sulfate 1. A community health nurse is performing a vision screening on a 4 month old infant. When shining a light source into the infant's visual field, which of the following is an expected finding? - Correct Answerthe infant closes their eyes 1. A nurse is teaching a client and their family about home hospice care. Which of the following information should the nurse include in the teaching? - Correct Answera. Hospice care improves quality of life through palliative care 1. A nurse is preparing to administer eye drops to a client. Which of the following nursing actions is appropriate? - Correct Answera. Use aseptic technique and drop the medication into the conjunctival sac 1. A nurse manager at a public health clinic is concerned about the rising number of sexually transmitted infections in the community. The purpose of which of the following is to generate new ideas to address the public health concern? - Correct Answera. A brainstorming session with nurses 1. A nurse is teaching a group of farmworkers who work with pesticide about minimizing exposure. Which of the following information should the nurse include in the teaching? - Correct Answera. Change clothes after working in the field 1. A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions should the nurse take? - Correct Answera. Monitor for abdominal ascites 1. A nurse is caring for a client who is receiving systematic desensitization therapy to treat agoraphobia. Which of the following client statements should indicate to the nurse that the treatment has been effective? - Correct Answera. I was able to sit on a park bench for 30 minutes 1. A nurse is caring for a client who is receiving a blood transfusion at 125mL/hr and develops a hemolytic reaction. Which of the following actions should the nurse perform? - Correct Answera. Infuse 0.9% sodium chloride IV 1. A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse? - Correct Answera. The gastric residual volume is 250 mL following 2 hr of infusion 1. A nurse is providing postoperative teaching to a client who has a newly-inserted pacemaker. Which of the following statements by the client indicates that the teaching has been effective? - Correct AnswerI will use my cell phone on the ear opposite of my pacemaker 1. A nurse in a mental health facility is evaluating the effectiveness of mechanical restraints for a client who threw a chair in the day room. The nurse should identify which of the following findings as an indication to remove the restraints? - Correct Answera. The client apologizes for their aggressive behavior 1. A nurse is preparing to administer an IV bolus of albumin 5% to a client who is receiving a continuous IV infusion. After confirming compatibility, which of the following actions should the nurse take? - Correct Answera. Occlude the IV tubing above the injection port 1. A nurse is caring for a client who is postpartum and has a new prescription for methylergonovine for vaginal bleeding refractory to fundal massage and oxytocin. When reviewing the client's medical history, the nurse should recognize which of the following diagnoses as a contraindication to the administration of methylergonovine? - Correct Answerhypertension 1. A nurse is caring for a client who has a prescription for vancomycin 1 g IV every 12 hr. The client is scheduled to have the morning dose at 0700. The nurse should schedule the trough level to be drawn at which of the following times? - Correct Answer1800 1. A nurse is performing a skin assessment for a client who is on bedrest. Which of the following actions should the nurse take to prevent a pressure injury? - Correct Answera. Apply a donut ring pillow under the client's sacral area 1. A nurse from the State Health Development is instructing a group of nurses regarding reportable infections. Which of the following infections should the nurse report to the Centers for Disease Control and Prevention? - Correct Answerlyme disease 1. A nurse is performing an admission assessment for a client who is to undergo a colonoscopy. The client informs the nurse that he took his prescribed medications before coming to the clinic. Which of the following medications is the priority to report to the provider? - Correct Answerclopidogrel 1. A client asks the nurse if it is safe to take a glucosamine supplement. The nurse should assess for which of the following potential contraindications? - Correct Answershellfish allergy 1. A nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy with clozapine. Which of the following is the highest priority for the client to report to the provider? - Correct Answerfever 1. 2 hr postoperative following an ileal conduit procedure bladder cancer - Correct Answerdusky colored stoma 1. Administer an injection to a client when the client states, "I dont want that injection. The last time I got that was sore for a week - Correct Answerbattery 1. a nurse is interviewing a client who presents with multiple injuries that are consistent with intimate partner abuse. After establishing trust and rapport, which of the following should the nurse say? - Correct Answerlets talk about what happened to you 1. a nurse is teaching a prenatal class about evidence of effective breastfeeding to a group of parent - Correct Answerswallowing sounds are audible stool are yellow and seedy after 7 days maternal breasts become soft following feeds A community health nurse is preparing to collect data to study the health of a local community. The nurse should plan to obtain information about which of the following factors during a windshield survey? - Correct AnswerThe leading cause of death for the prior year A nurse is reviewing the laboratory report of a client who has a magnesium level of 1.0 men/ml. Which of the following assessment findings should the nurse expect? - Correct AnswerConfusion A nurse is caring for a client who has breast cancer and has been receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider? - Correct AnswerWBC 3,000 A nurse is planning teaching for a client who is at 10 weeks of gestation and has a history of urinary tract infections. Which of the following information should the nurse plan to include in the teaching about UTI prevention? - Correct AnswerEmpty the bladder before and after intercourse A nurse is teaching a client about nutritional intake. The nurse should include which of the following in the teaching? - Correct Answer"Carbohydrates should be at least 45% of your caloric intake. A nurse is performing high-frequency chest compressions using a mechanical chest compression device for a child who has cystic fibrosis. Which of the following findings indicates the treatment has been effective? - Correct AnswerThe child has increased sputum production A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique? - Correct AnswerThis technique decreases the risk of subcutaneous infiltration A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication - Correct AnswerDecreased reflexes client who had a CVA. perform to prevent foot dropping - Correct AnswerPlace positing boots on the client's feet A nurse in a provider's office is teaching a client 16 weeks of gestation and has a new prescription for ferrous sulfate. What should the nurse include in the teaching - Correct AnswerTake your iron with fluids other than coffee and tea A nurse is caring for a client who has a newly implanted sealed internal radiation device to treat cervical cancer. Which of the following is an appropriate action for the nurse to take? - Correct AnswerKeep a 3 foot distance from the radiation implant A charge nurse is evaluating the time management skills of a newly licensed nurse. Which of the following actions should the charge nurse identify as an effective time management skill? - Correct AnswerCompletes activities for one client before moving to the next client A nurse is performing an admission assessment for a client who is to undergo a colonoscopy. The client states he took all his meds before coming. which of the following medication is priority to report to the provider - Correct AnswerClopidegrel Four clients to an emergency department. The nurse should plan to see which of the following first? - Correct Answer50-year old client who has slurred speech, disoriented and reports a headache A nurse is teaching a group of newly hired nurses about placenta previa. Which of the following client findings should the nurse include? - Correct AnswerBright red vaginal bleeding A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood pressure. The nurse should identify that these findings are potential manifestations of which of the following? - Correct AnswerOpioid intoxication A nurse in a clinic is teaching a client who is postmenopausal about estrogen therapy. What should the nurse include in the teaching - Correct Answerestrogen therapy increase the risk for thrombus formation A nurse administers a dose of metoclopramide to a client prior to a chemotherapy treatment. The client develops uncontrolled contraction of the head and neck muscles. Which of the following medications should the nurse administer - Correct Answerdiphenhydramine A nurse on a med-surg unit is caring for a group of clients. Which of the following clients would benefit from a three-way indwelling catheter - Correct Answerfemale who is prone to development of blood clots in the urine A nurse is assessing the vital signs of a newborn who was born 8hrs ago. Which of the following findings require interventions by the nurse? - Correct AnswerBlood pressure 72/45 mmHg A nurse is caring for a postoperative client. Which of the following interventions will reduce the risk of DVT - Correct Answerapply venous plexus foot pumps A nurse is providing teaching about nutrition to the parents of a preschooler who has chronic renal failure. Which of the following indicates understanding teaching - Correct AnswerI should limit my child's intake of protein A nurse is assessing a client who has COPD and experienced recent weight loss. Which of the following findings should the nurse report to the provider? - Correct AnswerCoughing and wheezing after eating A nurse is caring for a group of clients. Which of the following clients should the nurse identify as being at risk for metabolic alkalosis? - Correct AnswerA client who has kidney failure At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first? - Correct AnswerIndigestion A nurse is caring for a group of clients in an inpatient mental health facility. Which of the following task should the nurse delegate to the AP - Correct AnswerSit with the client who has anorexia nervosa during meals A nurse is collecting a specimen for an aerobic culture from a client who has a draining pressure injury. Identify the sequence of actions the nurse should take? A,p,cl,o,b - Correct Answer1. Assess the appearance of the wound. 2. Place the swab in the culture tube c. Cleanse the wound with 0.9% sodium chloride irrigation d. Cover the wound with a sterile dressing e. Obtain the specimen from granulation tissue of the wound A nurse is teaching the parent of a school-age child who has scabies about the application of permethrin 5% cream. The nurse should include which of the following as a potential adverse effect of the medication? - Correct Answerburning A nurse is planning care for a client who has anew diagnosis of dysphagia. Which of the following foods should the nurse recommend? - Correct Answeroatmeal A nurse is caring for a client who has schizophrenia. the client's states "run cats soon the rain throwing procedure mechanical paper lake." The nurse should document that the client is demonstrating which of the following speech alterations? - Correct Answerword salad A nurse is preparing to administer eye drops to a preschooler who has conjunctivitis. Which of the following actions should the nurse take? - Correct Answermaintain the child in a sitting position 3 mins after An infection control nurse is reviewing the medical records of several clients. Which of the following infections should the nurse report to the centers for disease control and prevention? - Correct Answersyphilis A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV fusion. Which of the following should be reported to the provider - Correct AnswerMagnesium 9mEq/L A nurse is caring for a client who has meningitis. Which of the following assessments should the nurse perform? - Correct AnswerBrudzinski sign A nurse is providing dietary teaching to a client who has an increased cholesterol level. Which of the following foods should the nurse recommend? - Correct Answeregg whites A nurse is caring for a child who has a new prescription for chlorpromazine by IM injection. Which of the following is an appropriate action? - Correct AnswerCheck orthostatic blood pressure 1hr after administration A nurse is caring for a child who has infectious mononucleosis. Which of the following findings are associated with this diagnosis? Select all that apply - Correct Answersplenomegaly malaise sore throat A nurse is planning care for a newly admitted adolescent client who has bacterial meningitis. Which of the following instructions is appropriate for the nurse to include in the plan of care? - Correct Answerinitiate droplet precaution A nurse is caring for a client who has a chest tube and notes continuous bubbling in the water-seal chamber. Which of the following actions should the nurse take? - Correct Answercheck for an air leak A nurse is caring for a client who has a new prescription for lithium carbonate. Prior to administering the first dose, which of the following laboratory values should the nurse evaluate? - Correct AnswerThyroid hormones A nurse is preparing to administer an IV bolus of albumin 5% to a client receiving a continuous IV infusion. What action should the nurse take - Correct Answeruse the injection site farthest away from the IV insertion site A nurse is preparing to discharge a client who is to be transferred to a long-term care facility. The nurse should recognize that which of the following actions is a breach of client confidentiality? - Correct AnswerDiscussing the clients reaction to the transfer with another staff nurse A nurse is delegating task to an AP. For which of the following can the nurse assign to the AP to measure vital signs - Correct AnswerA client who is requesting pain medication 2 days after surgery A circulating nurse is implementing a "time-out" before moving a client who is having total hip arthroplasty to the surgical site. Which of the following actions should the nurse take. - Correct Answerconfirm the provider has marked the surgical site A nurse is caring for a client who is taking allopurinol. The nurse should monitor which of the following laboratory findings to determine the effectiveness of the medication? - Correct Answeruric acid level A nurse is assessing a client who has pericarditis. Which of the following findings is the priority? - Correct Answerparadoxicalpulse A client who is 8hr postpartum asks the nurse id she will nee to receive Rh immune globulin. The client is gravid 2, para 2, and her blood type is AB negative. The newborn's blood type is B positive. Which of the following statement is appropriate ? - Correct Answershould be given 72 hrs after delivery The nurse is caring for a client who is receiving lactated ringers to treat fluid volume deficit. The nurse should identify that which of the following findings indicates a therapeutic response to the treatment? - Correct AnswerIncreased hemoglobin and hematocrit levels neutropenia about food safety to prevent food borne illness - Correct AnswerRefrigerate leftover with 2 hrs A nurse is caring for a female client who has bruises on her arms that she explains are result of physical abuse by her partner. - Correct AnswerHelp the client to recognize the signs of escalation of abusive behavior A nurse is providing postoperative teaching to a client who has a newly inserted pacemaker. Which of the following statements by the client indicates that the teaching has been effective? - Correct AnswerI will use my cellphone on the ear opposite of my pacemaker a nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy with clozapine. Which of the following is priority to report to the provider - Correct Answerfever A nurse is performing a vision screening for a client. Which of the following finding should the nurse identify as an indication that the client has cataract - Correct Answerincreased opacity of the lens of the eye A nurse is assessing a client who is postoperative following abdominal surgery. The client states, "I feel like my incision ripped open." The nurse notes dehiscence of the incision. Which of the following actions should the nurse take? - Correct Answerplace the client in low fowler's A nurse is caring for a client who has a newly implanted sealed internal radiation device to treat cervical cancer. Which of the following is an appropriate action for the nurse to take? - Correct AnswerWear a lead apron A nurse is planning an educational session for a client who has type 1 diabetes mellitus. Which of the following should the nurse plan to include when teaching the client to monitor for hypoglycemia - Correct Answerdiaphoresis A nurse is inserting an IV catheter for a client who requires fluid replacement. Which of the following actions should the nurse take - Correct AnswerApply the tourniquet 15cm(6in) about the insertion site A nurse is instructing a group of newly hired nurses about medication to promote fetal lung maturation. which of the following medications should the nurse include in the instructions? - Correct Answerbetamethsone A nurse is planning care for a newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care - Correct AnswerAssess the infants eyes for corneal irritation every 4hrs A nurse is caring for a client who is racing a controlled epidural analgesia infusion. Which of the following nursing action is appropriate? - Correct AnswerReplacing the infusion tubing every 72 hrs A nurse is caring for a school age child who has a blood pressure of 88/50 mm Hg and develop sepsis shock. Which of the following medication should the nurse expect to be prescribed? - Correct AnswerDopamine A nurse is caring for a toddler who has RSV. Which of the following actions should the nurse plan to take? - Correct Answeruse a designated stethoscope when caring for the toddler A nurse is assessing a client who has pneumonia. Which of the following findings is the priority for the nurse to report to the provider? - Correct AnswerChange in vocal tone after drinking liquids A nurse manager is making staffing assignments for the medical-surgical unit. Which of the following clients is appropriate to assign to a float nurse from the postpartum unit? - Correct AnswerA client who is 2 days post following a colon resection. A nurse in a mental health facility is interviewing a newly admitted client. Which of the following actions should the nurse take when conducting the interview? - Correct AnswerInsist the client use direct eye contact during the interview atrial fibrillation - Correct AnswerC A nurse is assessing a client who has minor injuries following a motor-vehicle crash and appears agitated and apprehensive. The nurse identifies that the client is in the alarm stage of general adaption syndrome and should expect which of the following findings? - Correct Answertachycardia A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65ml/hr through gastrostomy tube. Which of the following findings requires immediate interventions by the nurse? - Correct AnswerThe client is lying in a supine position. A nurse is teaching a prenatal class about evidence of effective breastfeeding to a group of parents. Which of the following information should be included - Correct AnswerNewborn swelling sound are audible while breastfeeding Newborn stools are yellow and seedy after 7 days of breastfeeding Maternal breast become soft following feedings. A client who has a diagnosis of complete placenta previa is admitted to the labor and delivery suite at 36 weeks gestation with contractions 5 min in frequency and 1 min in duration. Which of the following actions should the nurse take? A. Rupture the amniotic sac B. Medicate the client for pain C. Prepare the client for a cesarean section D. Perform a vaginal exam - Correct AnswerPrepare the client for a cesarean section A nurse enters a client's room and finds the client lying on the floor in a puddle of water. Which of the following statements should the nurse document in an incident report? A. Client fell out of bed because an assistive personnel left the rails of the bed down B. Client's roommate thinks the client is confused and fell when getting out of bed C. Client appears to have slipped in water but reports no injuries D. Client found lying on the floor near the bedside table - Correct AnswerClient found lying on the floor near the bedside table A charge nurse on a pediatric unit is making assignments for a float nurse from the medical unit. Which of the following clients is appropriate to assign to the float nurse? A. A 10-year-old client who has pneumonia and is receiving respiratory treatments B. A 4-year-old client who has a Wilms tumor and is receiving chemotherapy C. An 8-month-old client who is scheduled for a surgical repair of a ventricular septal defect tomorrow D. A 14-year-old client who is scheduled for discharge today following placement of a Herrington rod - Correct AnswerA 10-year-old client who has pneumonia and is receiving respiratory treatments A nurse is preparing to administer vancomycin to a client who has an infected wound. The nurse should plan to monitor for which of the following adverse reactions? A. Hepatotoxicity B. Ototoxicity C. Hypercalcemia D. Hypertension - Correct AnswerOtotoxicity A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect? A. Generalized edema B. Elevated urine specific gravity C. Thready pulse D. Increased hematocrit - Correct AnswerGeneralized edema A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client has two school-age children and a limited support system. Which of the following is the priority nursing action? A. Inform the client of available community resources B. Assist the client in finding childcare options C. Agree upon short-term goals for the client D. Ask the client about their understanding of the diagnosis - Correct AnswerInform the client of available community resources A nurse in an emergency department is assessing a client who has a nasal fracture. Which of the following findings should cause the nurse to suspect a skull fracture? A. Clear fluid drainage from the nares B. Report of pain around the eyes C. Dried blood in the mouth D. Mandibular asymmetry - Correct AnswerClear fluid drainage from the nares A nurse in an urgent care clinic is collecting admission history from a client who is at 16 weeks of gestation and has bacterial vaginosis. The nurse should recognize that which of the following clinical findings are associated with this infection? A. Profuse milky white discharge B. Frequency and dysuria C. Low-grade fever D. Hematuria - Correct AnswerProfuse milky white discharge A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique? A. This technique prevents injury to the sciatic nerve B. This technique decreases the risk of subcutaneous infiltration C. This technique allows a larger amount of medication to be injected A. Cleanses the wound with povidone-iodine with cotton balls B. Administers PO analgesia 20 min prior to irrigation C. Warms the irrigation solution in the microwave oven prior to application D. Irrigates the wound from the top to the bottom - Correct AnswerIrrigates the wound from the top to the bottom A nurse is planning care for a child who has increased intracranial pressure with a decrease in level of consciousness. Which of the following interventions should the nurse include in the plan of care? A. Perform active range-of-motion exercises B. Maintain the head at a midline position C. Suction the airway frequently D. Perform neurological checks every 4 hrs - Correct AnswerMaintain the head at a midline position A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket. After moving the client to safety, which of the followings is the priority action? A. Notify the facility operator B. Close the fire doors on the unit C. Turn off oxygen sources D. Put out the fire with the appropriate extinguisher - Correct AnswerClose the fire doors on the unit A nurse is talking with an adult child of a client who was involuntarily admitted to an inpatient mental health facility. Which of the following statements should the nurse make? A. The provider will notify your patient's employer about admission to the facility B. Your parent will have to take the medication that the doctor prescribes C. Your parent might have electroconvulsive therapy without providing consent D. The provider can prescribe restraints if your parent tries to harm others - Correct AnswerThe provider can prescribe restraints if your parent tries to harm others A nurse is assessing a client who has delirium due to a febrile illness. Which of the following findings should the nurse expect? A. Hallucinations B. Agnosia C. Bradycardia D. Aphasia - Correct AnswerHallucinations A nurse is assessing a client who is receiving enteral feedings via a gastrostomy tube. The nurse should identify that which of the following findings indicates fluid overload? A. Diminished bowel sounds B. Bradycardia C. Hypotension D. Bounding pulses - Correct AnswerBounding pulses A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing? A. INR 1.1 B. Hyperemesis C. HbA1c 5.6% D. Uncontrolled pai - Correct AnswerHyperemesis A nurse is assessing a client who has a complete heart block and is receiving transcutaneous pacing. Which of the following findings indicates to the nurse that the treatment is effective? A. Heart rate greater than 60/min B. Pedal pulses 2+ C. Pacer spikes after the QRS complex D. Distended jugular vein - Correct AnswerHeart rate greater than 60/min A nurse is caring for a client who is taking levothyroxine. Which of the following findings should indicate to the nurse that the medication is effective? A. Decreased blood pressure B. Weight loss C. Decreased inflammation D. Absence of seizures - Correct AnswerWeight loss A nurse at the family planning clinic triages several client over the phone. Which of the following clients should the nurse instruct to come to the clinic? A. A client who uses a diaphragm for contraception and has lost 30 lb in the past 6 months dieting B. A client who had an intrauterine device inserted yesterday and has cramping and bleeding C. A client who has started taking oral contraceptives and is experiencing bright red vaginal breakthrough bleeding D. A client who has sharp pain in her shoulder following a laparoscopic tubal ligation yesterday - Correct AnswerA client who has sharp pain in her shoulder following a laparoscopic tubal ligation yesterday A home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The nurse should evaluate which of the following laboratory tests to determine effective long-term management of blood glucose levels? A. 3-hr oral glucose tolerance test B. HbA1c C. Fasting blood glucose test D. Urinalysis for ketone - Correct AnswerHbA1c A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client? A. Wear an N95 respirator B. Insert an indwelling urinary catheter to monitor urinary output C. Monitor the client's vital signs every 8 hr D. Use a dedicated stethoscope - Correct AnswerUse a dedicated stethoscope A nurse is planning care for a client who has a gambling disorder. Which of the following instructions should the nurse provide to the client? A. Participate in a 12-step program B. Plan to take clozapine for the next 6 months C. Use systematic desensitization to decrease gambling behaviors D. Learn to use projection to adapt to stressful experiences - Correct AnswerParticipate in a 12-step program A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take? A. Encourage the client to ambulate in the hallway 1 hr before bedtime B. Tell the client to avoid drinking fluids 1 hr before bedtime C. Schedule routine care tasks during hours when the client is awake D. Advise the client to leave the television in the room on when trying to fall asleep - Correct AnswerTell the client to avoid drinking fluids 1 hr before bedtime A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. D. Heart rate 152/min - Correct AnswerHeart rate 152/min A client who is having suicidal thoughts tells the nurse, "It just does not seem worth it. Why not end my misery?" Which of the following responses by the nurse is appropriate? A. Why do you think your like is not worth it anymore? B. You can trust me and tell me what you are thinking? C. I need to know what you mean by misery? D. Do you have to plan to end your life? - Correct AnswerDo you have to plan to end your life? A nurse is caring for a client who has schizophrenia. Which of the following findings is the nurse's priority? A. The client asks other clients on the unit for help with bathing and getting dressed B. The client refuses to take prescribed oral risperidone C. The client reports hearing voices D. The client's thoughts jump rapidly from one idea to the next when speaking - Correct AnswerThe client reports hearing voices At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first? A. Constipation B. Indigestion C. Swollen ankles D. Urinary frequency - Correct AnswerIndigestion A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following actions by the assistive personnel requires the nurse to intervene? A. Encourages the client to use the incentive spirometer B. Elevates the head of the client's bed C. Offers oral fluids to the client D. Checks the client's pulse oximetry - Correct AnswerOffers oral fluids to the client A nurse is reviewing the medical history of a client who is taking a garlic supplement. The nurse should identify that which of the following findings is a contraindication for taking this supplement? A. The client is taking an antidepressant B. The client has a history of a seizure disorder C. The client takes aspirin daily D. The client has a history of rheumatoid arthritis - Correct AnswerThe client takes aspirin daily A nurse in a mental health facility is interviewing a newly admitted client. Which of the following actions should the nurse take when conducting the interview? A. Insist the client use direct eye contact during the interview B. Seat the client at least 3.7m from the nurse C. Position the client's chair between the nurse's chair and the door D. Lean in slightly when speaking to the client - Correct AnswerLean in slightly when speaking to the client A nurse on a medical unit has just received change-of-shift report. Which of the following clients should the nurse assess first? A. A 68-year-old client who had a myocardial infarction 2 days ago and reports chest pain on a scale of 0 to 10 B. A 48-year-old client who has AIDS, pneumocystis pneumonia, and a temperature of 38.3 C (101F) C. A 60-year-old client who has COPD, is receiving 2 L/min O2 via a nasal cannula, and has an oxygen saturation of 89% D. A 26-year-old female client who has pelvic inflammatory disease and is unable to void - Correct AnswerA 68-year-old client who had a myocardial infarction 2 days ago and reports chest pain on a scale of 0 to 10 A nurse is assessing a client prior to performing a blood draw. The nurse should identify that an allergy to which of the following food can indicate that the client has an allergy to latex? A. Peanuts B. Shellfish C. Avocados D. Eggs - Correct AnswerAvocados A nurse is planning discharge teaching for a client who is scheduled to receive intravenous infusions at home. Which of the following instructions should the nurse plan to include? A. Plug the infusion pump in an outlet next to the bathroom B. Pull the cord when unplugging the infusion pump C. Clean the infusion pump when it is turned on D. Place the infusion pump cord against the baseboards - Correct AnswerPlace the infusion pump cord against the baseboards A nurse is preparing to witness a client's signature on an informed consent for a total knee arthroplasty. Which of the following client statements indicates the nurse should contact the surgeon? A. I wonder if the metal in my knee will show up in airport screenings B. The physical therapy has not been working, so I will need to have the surgery C. I look forward to being able to bend my knee again when I sit in a chair D. I am thankful there are no serious complications from this type of surgery - Correct AnswerI am thankful there are no serious complications from this type of surgery A nurse plans to ambulate a client on the third day after cardiac surgery. Which of the following interventions should the nurse take so that the client will best tolerate ambulation? A. Provide the client with a water B. Premedicate the client with the prescribed analgesic C. Obtain the client's vital signs and oximetry prior to ambulation D. Reinforce the client's surgical dressing - Correct AnswerPremedicate the client with the prescribed analgesic A nurse is planning the discharge of an infant who has tetralogy of Fallot. The nurse anticipates the need for which of the following equipment? A. Portable suction B. Cervical collar C. Hemodialyzer D. Pulse oximeter - Correct AnswerPulse oximeter A nurse is admitting a client who has antisocial personality disorder. Which of the following client behaviors should the nurse identify as consistent with this disorder? A. Compulsive attention to details B. Avoids interacting with others C. Uses others for personal gain C. Respiratory rate 14/min D. Potassium level 4.8 mEq/L - Correct AnswerNo bowel movement for 3 days A nurse is providing teaching to a client who has osteoporosis and a new prescription for alendronate. Which of the following statements by the client indicates an understanding of the teaching? A. "I will take this medication within 15 minutes of eating." B. "I will take this medication at bedtime." C. "I will take this medication with 8 ounces of water." D. "I will increase my caffeine intake while taking this medication." - Correct Answer"I will take this medication with 8 ounces of water." A nurse is caring for a client who experienced a stroke and has dysphagia. Which of the following findings should indicate to the nurse the client is at risk for aspiration? A. The client tucks his chin while swallowing food B. The client sits upright in bed during meals C. The client pockets food on one side of his mouth D. The client has a cough reflex - Correct AnswerThe client pockets food on one side of his mouth A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an assistive personnel? A. A client who has chronic obstructive pulmonary disease and needs guidance on incentive spirometry B. A client who had a myocardial infarction 3 days ago and reports chest pain C. A client who had a stroke 2 days ago and needs help toileting D. A client who has awoken following a bronchoscopy and requests a drink - Correct AnswerA client who had a stroke 2 days ago and needs help toileting A nurse is caring for a client who is receiving continuous enteral feedings and reports diarrhea. Which of the following actions should the nurse take? A. Discard opened cans of formula after 24 hrs B. Replace the extension tubing every 48 hrs C. Irrigate the tubing every 12 hr with 50 mL of warm water D. Increase the infusion rate - Correct AnswerDiscard opened cans of formula after 24 hrs A nurse is caring for an adolescent who is receiving treatment for heart failure. Based on the client's chart findings, which of the following actions should the nurse plan to take? A. Administer furosemide B. Withhold digoxin C. Withhold spironolactone D. Administer ferrous sulfate - Correct AnswerWithhold digoxin A nurse is reviewing the employee health program for new employees. Which of the following diagnostic assessments should the nurse recommend for all new employees to screen for the presence of tuberculosis? A. Sputum culture B. Chest x-ray C. QuantiFERON-TB Gold blood analysis D. Mantoux test - Correct AnswerMantoux test A nurse is providing teaching about car seat safety to the parent of a term newborn. Which of the following statements by the parent indicates an understanding of the teaching? A. "I should place a rolled blanket along each side of my baby's head in the car seat." B. "I should place my baby's car seat rear-facing until 6 months of age." C. "I should put the car seat retainer clip at the level of my baby's belly button." D. "I should position my baby's car seat at a 90-degree angle in the car." - Correct Answer"I should place a rolled blanket along each side of my baby's head in the car seat." A nurse in the labor and delivery unit is reviewing medications for a group of clients. Which of the following medications places the fetus at risk for teratogenic effects? A. Levothyroxine for hypothyroidism B. Phenytoin for seizure disorder C. Magnesium oxide for constipation D. Ferrous sulfate for chronic anemia - Correct AnswerPhenytoin for seizure disorder An emergency department nurse triages a group of school children injured in a school bus crash. Which of the following children should the nurse have the provider evaluate first? A. A child who has a forehead wound that is bleeding copiously B. A child who has a compound fracture of the femur and is crying in pain C. A child who reports diplopia and nausea and was unconscious at the scene but is now awake D. A child who has several missing permanent teeth and a swollen, ecchymotic upper lip - Correct AnswerA child who reports diplopia and nausea and was unconscious at the scene but is now awake A nurse is caring for a client who is receiving total parental nutrition. For which of the following findings should the nurse monitor as a potential complication of TPN? A. Constipation B. Respiratory depression C. Hypotension D. Electrolyte imbalance - Correct AnswerElectrolyte imbalance A nurse is analyzing the laboratory data on a client who has dehydration. Which finding should the nurse anticipate in a client who has fluid volume deficit? A. Decreased serum osmolarity B. Decreased hematocrit C. Elevated blood urea nitrogen D. Lower urine specific gravity - Correct AnswerElevated blood urea nitrogen A nurse is performing high-frequency chest compressions using a mechanical chest compression device for a child who has cystic fibrosis. Which of the following findings indicates the treatment has been effective? A. The child develops a dry, hacking cough B. The child has increased nasal secretions C. The child has increased sputum production D. The child develops diminished breath sounds - Correct AnswerThe child has increased sputum production A nurse in an inpatient mental health facility is caring for a client who has major depressive disorder and refuses to take her medication. Which of the following actions should the nurse take first? A. Explain to the client the consequences of refusal B. Identify the reason for the client's refusal B. Vomited a large amount of emesis immediately after surgery C. Flushed IV with 0.9% sodium chloride D. Pain relieved by position change - Correct AnswerPain relieved by position change A charge nurse is evaluating the time management skills of a newly licensed nurse. Which of the following actions should the charge nurse identify as an effective time management skill? A. Delegates creation of a client's teaching plan to a licensed practical nurse B. Completes activities for one client before moving to the next client C. Focuses on activities rather than objectives D. Skips break times to catch up on charting - Correct AnswerCompletes activities for one client before moving to the next client A nurse is caring for a client who has a prescription for atorvastatin. Which of the following client conditions is a contraindication to this medication? A. Hepatitis C B. Crohn's disease C. Peptic ulcer disease D. Bronchitis - Correct AnswerHepatitis C A nurse delegates tasks to a licensed practical nurse and an assistive personnel. When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN? A. Insert an indwelling catheter if the client has not voided in 3 hr B. Obtain the abdominal girth now and every 4 hr C. Assess and document the level of consciousness every hour D. Measure the amount of gastric drainage every 2 hr - Correct AnswerMeasure the amount of gastric drainage every 2 hr A nurse is assessing a client who has a long arm cast. For which of the following findings should the nurse monitor when assessing for acute compartment syndrome A. Edema B. Shortness of breath C. Petechiae D. Change in mental statu - Correct AnswerEdema A nurse is caring for a client who has opioid use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect? A. Hyperreflexia B. Meiosis C. Euphoria D. Hypothermia - Correct AnswerHyperreflexia A nurse is caring for a client who is at high risk for developing diabetes insipidus following a severe head injury. Which assessment finding indicates to the nurse that the client is developing DI? A. Urine specific gravity of 1.028 B. Urine output of 250 mL/hr C. Serum sodium of 155 mEq/L D. Blood glucose of 198 mg/dL - Correct AnswerUrine output of 250 mL/hr A nurse is planning to perform wound irrigation for a client who has an open secondary wound. When creating a sterile field, which of the following actions should the nurse take? A. Set up the sterile field 7.6 cm below waist level B. Hold the bottle of sterile solution with the palm over the label while pouring C. Place the sterile items within 1 cm of the edge of the sterile border D. Place the lid of a bottle of sterile solution within the sterile field - Correct AnswerHold the bottle of sterile solution with the palm over the label while pouring A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. Which of the following should the nurse expect? A. Head compression B. Fetal hypoxia C. Abruptio placentae D. Postmaturity - Correct AnswerHead compression A nurse is caring for a client who is requesting treatment for a gambling disorder. Which of the following medications should the nurse expect the provider to prescribe? A. Varenicline B. Disulfiram C. Sertraline D. Clonidine - Correct AnswerSertraline A charge nurse overhears two assistive personnel in the unit lobby discussing the HIV status of a client. Which of the following response is the priority for the nurse to make? A. Do you understand HIPAA regulations? B. This discussion is only appropriate in a private area C. Please stop this discussion D. Did you know you can be liable if you breach confidentiality - Correct AnswerPlease stop this discussion A nurse is planning care for a client who is prescribed a cane for ambulation. Which of the following actions should the nurse include in the plan of care? A. Remind the client to place the cane on the unaffected side B. Adjust the length of the cane to equal the distance from the client's iliac crest to the floor C. Remove the rubber tip from the cane to enhance ambulation D. Place the cane safely in the closet during naps and at bedtime - Correct AnswerRemind the client to place the cane on the unaffected side A nurse is planning care for a client who has a sealed radiation implant and is to remain in the hospital for 1 week. Which of the following should the nurse include in the plan of care? A. Limit each of the client's visitors to 1 hr per day B. Remove dirty linens from the room after double bagging C. Wear a dosimeter film badge while in the client's room D. Ensure family members remain at least 1 m from the client - Correct AnswerWear a dosimeter film badge while in the client's room A nurse is assessing a client who was brought to the emergency department by his adult child. The client has visible contusions on all four extremities. Which of the following actions should the nurse take? A. Report the incident to Adult Protective Services B. Interview the client with his adult child present C. Tell the client he must answer every assessment question D. Advise the client to consult a social worker - Correct AnswerReport the incident to Adult Protective Services A nurse in the recovery room is assessing a client who has a new chest tube. The nurse finds that the water seal is no longer tidaling. The nurse should identify the finding as resulting from which of the following? A. An air leak noted at the insertion site B. The tubing may be kinked C. Water needs to be added to the suction-control chamber D. The suction is set too low - Correct AnswerThe tubing may be kinked A nurse is assessing a client who has pericarditis. Which of the following findings is the priority? A. Dependent edema B. Pericardial friction rub C. Paradoxical pulse D. Substernal chest pain - Correct AnswerParadoxical pulse A nurse is assessing a client 1 week after a successful bone marrow transplant. The client reports peeling of skin on her hands and feet. The nurse should recognize this desquamation as an indication of which of the following complications? A. Failure to engraft B. Veno-occlusive disease C. Graft-versus-host disease D. Pancytopenia - Correct AnswerGraft-versus-host disease A client has just returned to the nursing unit following cardiac catheterization. In the immediate postprocedure period, which of the following is the priority nursing action? A. Monitoring the insertion site for infection B. Checking for orthostatic hypotension C. Forcing fluids D. Immobilizing the affect extremity - Correct AnswerImmobilizing the affect extremity A nurse is providing dietary teaching for a client who has a history of nephrolithiasis. Which of the following is appropriate to include in the teaching? A. Restrict dietary calcium intake B. Limit fluid intake to 40 oz/day C. Decrease complex carbohydrates in the diet D. Avoid foods that have high levels of oxalates - Correct AnswerAvoid foods that have high levels of oxalates A charge nurse is creating assignments for the next shift for several nurses and one of the nurses is pregnant. Which of the following clients should the charge nurse assign to a nurse who is not pregnant? A. A 60 year old client who is recovering from shingles B. A 20 year old client who is HIV positive C. A 40 year old client who is suspected of having tuberculosis D. An 80 year old client who has alcoholic pancreatitis and is being treated for impetigo - Correct AnswerA 60 year old client who is recovering from shingles A nurse is teaching a newly licensed nurse about informed consent. Which of the following statements should the nurse include in the teaching? (Select all that apply) A. By witnessing the signing of the informed consent form, the nurse is indicating that the client voluntarily gave consent B. A client who signs an informed consent form should understand the treatment plan C. A client who signs an informed consent form should be competent D. The nurse should disclose the purpose of the treatment before the client signs the consent form E. Signing the informed consent form indicates that the family agrees to the treatment options - Correct Answer- By witnessing the signing of the informed consent form, the nurse is indicating that the client voluntarily gave consent - A client who signs an informed consent form should understand the treatment plan - A client who signs an informed consent form should be competent A nurse is preparing to insert an indwelling catheter for a female client. Identify the sequence of actions the nurse should take - Correct Answer1. Apply sterile gloves and place cleansing balls in antiseptic solution 2. Attach prefilled syringe to indwelling catheter inflation hub 3. Lubricate the catheter and place fenestrated drape over perineum 4. Cleanse the meatus with the dominant hand in a downward motion 5. Insert the catheter until a flow of urine begins (aalci) A nurse in a substance use unit spends an equal amount of time with each of his assigned clients, even though some of the clients have committed serious crimes. Which of the following ethical principles is the nurse demonstrating? A. Justice B. Autonomy C. Nonmaleficence D. Veracity - Correct AnswerJustice A nurse is assessing a client who has a magnesium level of 4.4 mEq/L. Which of the following findings should the nurse expect? A. Hypotension B. Tachycardia C. Muscle cramps D. Hyperreflexia - Correct AnswerHypotension A nurse is reviewing the medical record of a client who has a new prescription for gentamicin. The nurse should identify that concurrent use with which of the following current medications can increase the client's risk for ototoxicity? A. Captropril B. Metoprolol C. Furosemide D. Hydrochlorothiazide - Correct AnswerFurosemide A nurse is preparing to administer 2.5mL of medication intramuscularly to an adult client. Which of the following is the safest site for the nurse to use? A. Ventrogluteal B. Dorsogluteal C. Vastus lateralis D. Rectus femoris - Correct AnswerVentrogluteal A nurse is performing triage following a natural disaster. Which of the following clients should the nurse identify as the highest priority to receive care? A. A client who has agonal respirations B. A client who has an open skull fracture and is unresponsive C. A client who has a traumatic arm amputation D. A client who has a fracture of the femur C. A client who is 1-day postoperative total hip replacement with a pain level of 7 on a scale of 0 to 10 D. A client who is coughing up pink-tinged sputum following a bronchoscopy and lung biopsy 1 hr ago - Correct AnswerA client who is coughing up pink-tinged sputum following a bronchoscopy and lung biopsy 1 hr ago A nurse is caring for a client following insertion of a subclavian nontunneled percutaneous central venous catheter. The provider writes a prescription to initiate an IV infusion of Ringer's lactate at 150 mL per hr. Prior to starting the infusion, which of the following actions should the nurse take? A. Apply oxygen at 3 L/min per nasal cannula B. Review the chest x-ray report C. Flush the catheter with sterile water D. Obtain a peripheral blood glucose level - Correct AnswerReview the chest x- ray report A nurse is planning care for a newly admitted client. Which of the following interventions should the nurse plan to take first? A. Initiate an IV access for the client B. Administer pain medication to the client C. Send the client to radiology for a CT scan D. Insert an NG tube for the client - Correct AnswerInitiate an IV access for the client A community health nurse is performing a vision screening on a 4-month-old infant. When shining a light source into the infant's visual field, which of the following is an expected finding? A. The infant's eyes turn toward the light B. The infant's head turns away from the light C. The infant's eyes remain focused toward the floor D. The infant closes their eyes - Correct AnswerThe infant closes their eyes A nurse is monitoring a client during an IV urography procedure. Which of the following client reports is the priority finding? A. Metallic taste in mouth B. Abdominal fullness C. Feeling flushed and warm D. Swollen lips - Correct AnswerSwollen lips A nurse is reviewing the history and physical of a client who has right ventricular heart failure. Which of the following is an expected finding? A. Crepitus B. Elevated pulmonary artery pressure C. Hepatosplenomegaly D. Confusion - Correct AnswerHepatosplenomegaly A nurse is teaching a client and their family about home hospice care. Which of the following information should the nurse include in the teaching? A. Hospice care improves quality of life through palliative care B. Hospice care provides 24 hr, in home care C. Hospice care is intended to postpone death D. Hospice care encourages the family to coordinate health care services - Correct AnswerHospice care improves quality of life through palliative care A nurse is preparing to administer eye drops to a client. Which of the following nursing actions is appropriate? A. Have the client tilt her head slightly so that the medication enters the nasolacrimal duct B. Gently wash away any exudate along the eyelid margin from the outside towards the inner canthus C. Use aseptic technique and drop the medication into the conjunctival sac D. Drop prescribed number of drops onto the cornea - Correct AnswerUse aseptic technique and drop the medication into the conjunctival sac A nurse suspects another nurse is chemically impaired during their shift. Which of the following is an appropriate action for the nurse to take? A. Report to the nurse manager B. Set up a time to meet with the nurse C. Assume care of the nurse's assigned clients D. Ask another staff nurse to confirm the suspicion - Correct AnswerReport to the nurse manager A nurse is providing teaching to an adolescent client who has cystic fibrosis and has a prescription for pancrelipase. Which of the following should the nurse include in the teaching? A. Take on an empty stomach B. Take 1 hr before meals C. Take 1 hr after meals D. Take with meals - Correct AnswerTake with meals A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply) A. The provider should renew the prescription for restraints every 48 hr B. The nurse should pad the bony prominences C. The nurse should tie the restraints using a square knot D. The nurse should remove the restraints every 2 hr E. The provider's prescription should include the type of restraint to use - Correct Answer- The nurse should pad the bony prominences - The nurse should remove the restraints every 2 hr - The provider's prescription should include the type of restraint to use A nurse is preparing a client for surgery and has just administered the preoperative injection. Which of the following actions should the nurse take? A. Take the client to the bathroom to void B. Ask the client to verify the surgical site C. Review deep breathing and coughing exercises D. Raise the side rails on the bed - Correct AnswerRaise the side rails on the bed A nurse is teaching the guardian of an infant who has developmental dysplasia of the hip about a Pavlik harness. Which of the following instructions should the nurse include? A. Adjust the straps on the harness once per week B. Use only ultra-thin diapers applied over the straps C. Maintain the child in a prone position while the harness is in place D. Gently massage the skin under the straps once per day - Correct AnswerGently massage the skin under the straps once per day A charge nurse is teaching a group of unit nurses about the policy for clients who have a history of methicillin-resistant Staphylococcus aureus. Which of the following information should the nurse include? A. A client who has an ileal conduit and mucus in the pouch B. A client who has an arteriovenous fistula that vibrates when palpated C. A client who had a transurethral resection of the prostate with red-tinged urine in the bag D. A client who has chronic kidney disease with cloudy dialysate outflow - Correct AnswerA client who has chronic kidney disease with cloudy dialysate outflow A nurse is caring for a client who is receiving systematic desensitization therapy to treat agoraphobia. Which of the following client statements should indicate to the nurse that the treatment has been effective? A. I have been able to watch a church service on television without anxiety B. I was able to sit on a park bench for 30 minutes C. I enjoyed a visit from four of my work friends at my house D. I had a panic attack when driving by the grocery store - Correct AnswerI was able to sit on a park bench for 30 minutes A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires interventions by the nurse? A. 1 cm of water present in the water seal chamber B. Tidaling with spontaneous respirations C. Suction chamber pressure of -20 cm H20 D. Drainage collection chamber is one-third full - Correct Answer1 cm of water present in the water seal chamber nurse is caring for a client who is receiving a blood transfusion at 125mL/hr and develops a hemolytic reaction. Which of the following actions should the nurse perform? A. Infuse 0.9% sodium chloride IV B. Administer an antipyretic C. Decrease the infusion rate to 75 mL/hr D. Place the client in a left lateral position - Correct AnswerInfuse 0.9% sodium chloride IV A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse? A. The gastric residual volume is 250 mL following 2 hr of infusion B. The client is lying in a supine position C. The infusion pump for administering continuous feeding is turned off D. The enteral feeding bag and tubing are not dated - Correct AnswerThe gastric residual volume is 250 mL following 2 hr of infusion A nurse is assessing a client's cardiovascular system. Identify where the nurse should place the diaphragm of the stethoscope to best hear the closing of the aortic heart valve. - Correct AnswerA A nurse is performing change of shift assessments for four clients. Which of the following findings should the nurse report to the provider first? A. A client who has gastroenteritis and is lethargic and confused B. A client who has cystic fibrosis, has a thick, productive cough, and reports thirst C. A client who has sickle cell anemia and reports pain 15 minutes after receiving oral analgesic D. A client who has diabetes mellitus and has a morning fasting capillary glucose of 185 mg/dL - Correct AnswerA client who has gastroenteritis and is lethargic and confused A nurse on a labor and delivery unit is assessing four newly admitted clients. Which of the following clients should the nurse see first? A. A client who is at 38 weeks of gestation and reports irregular uterine contractions B. A client who is at 39 weeks of gestation and is scheduled for a weekly nonstress test. C. A client who is at 40 weeks of gestation and is scheduled for an induction of labor D. A client who is at 36 weeks of gestation and reports decreased fetal movement for 2 days - Correct AnswerA client who is at 36 weeks of gestation and reports decreased fetal movement for 2 days nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions? A. Varicella-zoster B. Vancomycin-resistant enterococcus C. Pertussis D. Rotavirus - Correct AnswerPertussis A nurse is evaluating the allergy profile of a client who has Graves' disease and is to undergo a thyroid scan. The nurse should identify which of the following allergies as a contraindication for the client to undergo a thyroid scan? A. Eggs B. Latex C. Peanuts D. Iodine - Correct AnswerIodine A nurse discovers that the wrong dosage of a medication was given to a client. When determining what action to take, the nurse should recognize that which of the following ethical principles should be applied? A. Utility B. Paternalism C. Fidelity D. Veracity - Correct AnswerVeracity A nurse is providing postoperative teaching to a client who has a newly-inserted pacemaker. Which of the following statements by the client indicates that the teaching has been effective? A. I will use my cell phone on the ear opposite of my pacemaker B. I can play softball with my family in 3 weeks C. I should perform arm exercises daily D. I will go to my cardiologist's office when the battery needs to be changed - Correct AnswerI will use my cell phone on the ear opposite of my pacemaker A nurse is observing bonding between a client and her newborn. Which of the following actions by the client requires the nurse to intervene? A. Holding the newborn in an en face position B. Asking the father to change the newborn's diaper C. Viewing the newborn's actions to be uncooperative D. Requesting the nurse take the newborn to the nursery so she can rest - Correct AnswerViewing the newborn's actions to be uncooperative A nurse in a mental health facility is evaluating the effectiveness of mechanical restraints for a client who threw a chair in the day room. The nurse should identify which of the following findings as an indication to remove the restraints? D. Hepatitis A can be spread by fecal-oral contac - Correct AnswerHepatitis A can be spread by fecal-oral contact A home health nurse is admitting a client who is prescribed peritoneal dialysis. Which of the following actions should the nurse take first? A. Confirm schedule for delivery of supplies B. Coordinate interdisciplinary health care services C. Demonstrate how to perform the procedure D. Clarify the client's actual and perceived health needs Demonstrate how to perform the procedure - Correct AnswerClarify the client's actual and perceived health needs A nurse is performing an admission assessment for a client who is to undergo a colonoscopy. The client informs the nurse that he took his prescribed medications before coming to the clinic. Which of the following medications is the priority to report to the provider? A. Metoprolol B. Clopidogrel C. Metformin D. Digoxin - Correct AnswerClopidogrel A client asks the nurse if it is safe to take a glucosamine supplement. The nurse should assess for which of the following potential contraindications? A. Shellfish allergy B. History of smoking C. Cardiac dysrhythmia D. Family history of malignant hyperthermia - Correct AnswerShellfish allergy A nurse is providing grief couseling for the parents of a school-age child whose sibling recently died. Which of the following statements should the nurse make? A. Try to suppress your grief when your child is present B. Avoid discussing the funeral when your child is around C. Bring the child to the funeral service before visitors arrive D. School-age children tend to view death as a temporary form of sleep - Correct AnswerBring the child to the funeral service before visitors arrive A nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy with clozapine. Which of the following is the highest priority for the client to report to the provider? A. Blurred vision B. Dry mouth C. Fever D. Constipation - Correct AnswerFever A nurse is caring for a client who received 2 units of packed RBCs 12 hr ago. Which of the following findings should indicate to the nurse the treatment was effective? Hct 36% Hgb 15 g/dL Platelets 10,000/mm3 RBC count 4.1 million/mm3 - Correct AnswerHgb 15 g/dL A nurse is caring for the guardian of an adolescent who was killed in a motor-vehicle crash. The guardian states, "I never should have let them take the car. It's all my fault!" Which of the following responses should the nurse make? "You had no way of knowing this would happen." "Why do you feel this is your fault?" "You appear to be feeling overwhelmed." "I know how you feel; I also lost a child." - Correct AnswerYou appear to be feeling overwhelmed." A nurse is planning care for a newly admitted client. Which of the following interventions should the nurse plan to take first? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) Exhibit 2 History and Physical Demographic Data Age: 56 Sex: Male Admitting Diagnosis: Acute pancreatitis Pain level of 8 on a scale from 0 to 10 Skin appears jaundiced History of alcohol use disorder a. Initiate an IV access for the client. b. Administer pain medication to the client. c. Send the client to radiology for a CT scan. d. Insert an NG tube for the client - Correct AnswerInitiate an IV access for the client A nurse is assessing a client who has the following vital signs: oral temperature 37.2° C (98.9° F), apical pulse rate 80/min, radial pulse rate 62/min, respiratory rate 16/min, and blood pressure 132/40 mm Hg. What is the client's pulse pressure? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) - Correct Answer92 A nurse in an emergency department is caring for a client who has multiple wounds due to a motor- vehicle crash. Which of the following actions should the nurse take? (Select all that apply.) A. Administer 650 mg aspirin PO as needed for pain. B. Cover the wounds with a sterile dressing. C. Apply direct pressure to bleeding wounds. D. Determine the date of the client's last tetanus toxoid immunization. E. Clean the lacerations and abrasions with hydrogen peroxide. - Correct Answer- Cover the wounds with a sterile dressing. - Apply direct pressure to bleeding wounds. - Determine the date of the client's last tetanus toxoid immunization. A nurse is developing an in-service for a group of antepartum clients about recommended nutritional intake. Which of the following nutrients should the nurse recommend the clients consume daily? A. Magnesium 200 mg B. Folate 600 mcg C. Calcium 700 mg D. Vitamin A 900 mcg - Correct AnswerFolate 600 mcg A nurse is providing preoperative teaching to a client who will use PCA morphine sulfate following surgery. Which of the following information should the nurse include? Family members can administer a dose for the client. A. The client can administer a dose of medication every 6 to 8 min. B. The client should notify the nurse when administering a dose of the medication. C. The PCA pump will be discontinued while the client is sleeping. D. The PCA pump will be discontinued while the client is sleeping - Correct Answerthe client can administer a dose of medication every 6 to 8 min. performance. Use all the steps.) ad,cl,ap,the,splint - Correct Answer1. Administer an analgesic. 2. Cleanse the wound. 3. Apply a thin layer of topical medication. 4. Apply the dressing to cover the area. 5. Splint the grafted extremity A nurse is caring for a client who has schizophrenia. The nurse should expect the client to exhibit which of the following manifestations? (Select all that apply.) Repeats the words of others when speaking Speaks in word salad Expresses interest in ADLs Has a blunt affect Experiences delusions - Correct Answer- Repeats the words of others when speaking - Speaks in word salad - Has a blunt affect - Experiences delusions A nurse is assessing a client who has disorganized, incoherent speech with loose associations and religious content. Which of the following conditions should the nurse expect that the client might be experiencing? A. Alcohol intoxication B. Alzheimer's disease C. Major depressive disorder D. Schizophrenia spectrum disorder - Correct AnswerSchizophrenia spectrum disorder A nurse manager is teaching a newly licensed nurse about documenting information in the client's medical record. Which of the following entries by the newly licensed nurse indicates an understanding of the teaching? A. "Client is uncooperative and refused to take morning medication." B. "2 cm by 2 cm amt of purulent drainage noted during dresing change." C. "Medication error made on previous shift. Client vital signs are stable." D. "Client administered 4 U of reg insulin." - Correct Answer"Client is uncooperative and refused to take morning medication." A nurse is caring for a client who has lactose intolerance and eliminated dairy products from their diet. The nurse should instruct the client to increase consumption of which of the following foods? A. Ground beef B. Peanut butter C. Kale D. Carrots - Correct AnswerKale