Ati RN Vati Comprehensive Predictor Form A Questions and correct answers., Exams of Nursing

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Ati RN Vati Comprehensive Predictor

Form A Questions and correct answers.

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 Answers Prepare 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 Answers Client 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 Answers A 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 Answers Ototoxicity 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 Answers Generalized 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 Answers Inform 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 Answers Clear 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 Answers Profuse 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 D. This technique increases the absorption rate of the drug - Correct Answers This technique decreases the risk of subcutaneous infiltration

10. A nurse is caring for a full-term newborn immediately following birth. Which of the following actions should the nurse take first? A. Instill erythromycin ophthalmic ointment in the newborn's eyes B. Weigh the newborn C. Place identification bracelets on the newborn D. Dry the newborn - Correct Answers Dry the newborn A nurse is planning to provide community education about viral hepatitis. Which of the following

should the nurse plan to include in the teaching? A. A series of four hepatitis vaccines is recommended to prevent viral hepatitis B. Hepatitis B is transmitted by contaminated food C. Chronic hepatitis can lead to renal cell cancer D. Clients who have a history of viral hepatitis are unable to donate blood - Correct Answers Clients who have a history of viral hepatitis are unable to donate blood A nurse in a residential mental health facility is planning care for a new client who has obsessive compulsive disorder. Which of the following is appropriate for the nurse to include in the plan of care? A. Work with the client to create a flexible daily schedule B. Gradually decrease the time allowed for ritualistic behavior C. Offer solutions to assist in problem solving D. Teach the client to meditate about obsessive thoughts - Correct Answers Gradually decrease the time allowed for ritualistic behavior A nurse is assessing an adult male who has a BMI of 20. The nurse should identify that the client's BMI falls within which of the following categories? A. Healthy weight B. Malnutrition C. Overweight D. Obesity - Correct Answers Healthy weight A nurse is caring for a client who is nulliparous and in the first stage of labor. The last internal assessment revealed 100% cervical effacement with 5 cm of dilation. At the end of the last contraction, the nurse observes a large gush of fluid coming out of the client's perineal area. Which of the following is a priority action by the nurse? A. Perform another internal exam B. Notify the client's provider

C. Check the FHR D. Obtain a pH test of the fluid - Correct Answers Check the FHR 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? A. Encourage the client to gain 2.3 kg per week B. Weigh the client once per week throughout hospitalization C. Monitor the client for 1 hr after meals D. Allow the client to choose mealtimes - Correct Answers Monitor the client for 1 hr after meals A nurse is performing a skin assessment on a client who has risk factors for development of skin cancer. The nurse should understand that a suspicious lesion is A. Asymmetric, with variegated coloring B. Scaly and red C. Brown, with a wart-like texture D. Firm and rubbery - Correct Answers Asymmetric, with variegated coloring A nurse is assessing a client's internal eye structures with an ophthalmoscope. Which of the following actions should the nurse take? A. Position the examination light toward the client's face B. Stand on the right side of the client when examining the left eye C. Dim the lights in the room prior to the examination D. Place the ophthalmoscope directly against the client's forehead - Correct Answers Dim the lights in the room prior to the examination A nurse is observing a newly licensed nurse irrigate a client's wound. Which of the following actions should the nurse identify as an indication that the newly licensed nurse understands wound irrigation? 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 Answers Irrigates 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 Answers Maintain 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 Answers Close 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 Answers The 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 Answers Hallucinations 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 Answers Bounding 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. B. Hyperemesis C. HbA1c 5.6% D. Uncontrolled pai - Correct Answers Hyperemesis 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 Answers Heart 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 Answers Weight 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 Answers A 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 Answers HbA1c 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 Answers Use 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 Answers Participate 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 Answers Tell 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. Which of the following interventions should the nurse include? A. Clothe the newborn in light cotton B. Check the newborn's temperature every 8 hrs. C. Administer 120 mL of water between feedings D. Place the newborn 45 cm from the light source - Correct Answers Place the newborn 45 cm from the light source A nurse is providing teaching to a client who is at 8-week gestation and experiencing episodes of nausea and vomiting. Which of the following instructions should the nurse include? A. Brush teeth immediately after eating B. Lay down for 30 min after meals C. Drink 12 oz of water with each meal D. Eat a dry carbohydrate before getting out of bed - Correct Answers Eat a dry carbohydrate before getting out of bed

A nurse is teaching a client who is scheduled for placement of a peripherally inserted central catheter line. Which of the following information should the nurse include in the teaching? A. Your PICC line will allow long-term access for antibiotic therapy B. You should use a 5-milliliter barrel syringe to flush your PICC line at home C. Your PICC line must be placed in your nondominant arm D. You should immobilize the arm with the PICC line using a sling - Correct Answers Your PICC line will allow long-term access for antibiotic therapy 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? A. Art therapist B. Speech-language pathologist C. Social worker D. Recreational therapist - Correct Answers Art therapist A nurse in a mental health clinic is observing clients in the day room. The nurse sits down to talk with an adolescent client who was admitted with clinical depression. After a few minutes of conversation, the adolescent asks the nurse, "Why did you choose to talk to me out of this room full of kids?" Which of the following responses by the nurse is therapeutic? A. You looked like you would be the most likely to talk back with me B. Let's go see what activities are going on outside C. Why shouldn't I talk to you? You looked lonely D. You're curious why I am interested in you and not the others? - Correct Answers You're curious why I am interested in you and not the others? An occupational health nurse at a group of health care clinics is planning activities to prevent and control the spread of communicable disease. The nurse should identify that which of the following

activities is a secondary level of prevention? A. Influenzas immunizations B. Tuberculosis screenings C. Presentations about safer sex practices D. Evaluations of bloodborne pathogen policies - Correct Answers Tuberculosis screenings 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? A. Decreased reflexes B. Weight gain of 1.4 kg C. Increased urinary output D. Jugular vein distention - Correct Answers Decreased reflexes A nurse is caring for a client who is postoperative following a bowel surgery and has an NG tube connected to low intermittent suction. Which of the following assessment findings should indicate to the nurse that the NG tube might not be functioning properly? A. Wall suction set to 60 mmHg B. Drainage fluid is greenish-yellow C. Aspirate pH of 3 D. Abdominal rigidity - Correct Answers Abdominal rigidity A nurse is caring for a 7-year-old child who has severe dehydration. Which of the following findings should the nurse expect? A. Blood pressure 94/68 mmHg B. Urinary output 30 mL/hr C. Respiratory rate 24/min D. Heart rate 152/min - Correct Answers Heart 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 Answers Do 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 Answers The 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 Answers Indigestion 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 Answers Offers 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 Answers The 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 Answers Lean 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 Answers A 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 Answers Avocados 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 Answers Place 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 Answers I 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 Answers Premedicate 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 Answers Pulse 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 D. Socially awkward in group situations - Correct Answers Uses others for personal gain 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? A. Burning B. Discoloration C. Photosensitivity D. Alopecia - Correct Answers Burning A nurse is teaching a client who has a new prescription for digoxin. Which of the following statements should the nurse include in the teaching? A. "Notify your provider if you experience muscle weakness." B. "Reports a weight gain of one-half pound per day."

C. "Expect this medication to increase your blood pressure." D. "You will need to take a diuretic while taking this medication. - Correct Answers "Notify your provider if you experience muscle weakness." 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? A. Decrease intake of citrus foods and beverages B. Wear nylon underwear C. Empty the bladder before and after intercourse D. Increase the time between voiding - Correct Answers Empty the bladder before and after intercourse A nurse is providing discharge teaching to a client who is postpartum and plans to breastfeed. Which of the following should the nurse recommend the client increase in their diet during lactation? A. Vitamin D B. Iron C. Vitamin A D. Calcium - Correct Answers Calcium A nurse is caring for a client who has been taking propranolol. Which of the following findings indicates a need to withhold the medication? A. Blood pressure 156/90 mm Hg B. Pulse 54/min C. Potassium 5.2 mEq/L D. Sodium 130 mEq/L - Correct Answers Pulse 54/min A nurse is providing teaching about preventing mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following instructions should the nurse include? A. "Wear an underwire bra between feedings."

B. "Cover your breasts immediately after feedings." C. "Apply cold compresses to your breasts before feedings." D. "Try to have your baby empty your breasts with each feeding - Correct Answers "Try to have your baby empty your breasts with each feeding A nurse is caring for a client who is receiving total parenteral nutrition. Which of the following findings requires immediate intervention by the nurse? A. Blood glucose level of 120 mg/dL B. Serum sodium 138 mEq/L C. Oral temperature of 37.6C D. Weight increase of 2 kg in the past 24 hours - Correct Answers Weight increase of 2 kg in the past 24 hours A nurse is caring for a client who reports chest pain. Which of the following findings indicates myocardial damage? A. aPTT 80 seconds B. Troponin I 1.8 ng/mL C. Erythrocyte sedimentation rate 17 mm/hr D. Human B-type natriuretic peptide 88 pg/mL 160 - Correct Answers Troponin I 1.8 ng/mL A nurse is assessing a client who has a fentanyl patch in place for chronic pain. Which of the following findings should the nurse report to the provider? A. No bowel movement for 3 days B. Report of dry mouth C. Respiratory rate 14/min D. Potassium level 4.8 mEq/L - Correct Answers No 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 Answers "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 Answers The 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 Answers A 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 Answers Discard 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 Answers Withhold 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 Answers Mantoux 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 Answers "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 Answers Phenytoin 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 Answers A 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 Answers Electrolyte 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 Answers Elevated 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 Answers The 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 C. Document the client's refusal in the medical record D. Inform the provider of the client's refusal - Correct Answers Identify the reason for the client's refusal A nurse is providing discharge teaching about disease prevention to a client who has active tuberculosis. Which of the following should the nurse include? A. Educating the client how to cover nose and mouth with tissues when coughing B. Recommending the client may return to work after two negative sputum cultures C. Instructing the client that he is no longer contagious after 1 week of medication therapy D. Teaching the client's family to wear protective masks while with the client - Correct Answers Educating the client how to cover nose and mouth with tissues when coughing A nurse is caring for a client following a possible exposure to anthrax. Which of the following actions should the nurse take?

A. Administer an antitoxin B. Quarantine the client C. Monitor the client for a productive cough D. Begin prophylactic treatment with ciprofloxacin - Correct Answers Begin prophylactic treatment with ciprofloxacin 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? A. Prohibit visitors for the first 24 hrs B. Keep a 3-foot distance from the radiation implant C. Maintain the client on bed rest for 72 hr D. Require the client wear a dosimeter badge - Correct Answers Keep a 3-foot distance from the radiation implant A nurse is admitting a client to the medical-surgical unit. Which of the following actions should the nurse take first? A. Place the client's valuables in the facility's safe B. Observe the client's level of mobility C. Administer prescribed medications D. Electronically enter the prescriptions from the provider - Correct Answers Observe the client's level of mobility A nurse is assessing a client in the PACU. Which of the following findings indicates decreased cardiac output? A. Oliguria B. Constricted pupils C. Shivering D. Bradypnea - Correct Answers Oliguria A nurse in a newborn nursery is performing assessments on four neonates that are all less than 24 hr old. The nurse should plan to notify the provider of which of the following findings?

A. Head circumference 1 cm greater than chest B. Positive Babinski reflex on bilateral feet C. Passage of meconium stool D. Pinna below the outer canthus of the eye - Correct Answers Pinna below the outer canthus of the eye A nurse is providing teaching to the guardian of a school-age child who has a new prescription for ferrous sulfate capsules PO. Which of the following instructions should the nurse include in the teaching? A. Add the contents of the capsules to food B. Dissolve the capsules in a glass of chocolate milk C. Administer the medication with a glass of orange juice D. Administer the medication at bedtime - Correct Answers Administer the medication with a glass of orange juice A nurse at a public health clinic is caring for a group of clients. Which of the following should the nurse identify as a reportable diagnosis to the CDC? A. Herpes simplex virus (HSV) type 1 B. Hepatitis A C. Human papillomavirus (HPV) D. Pediculosis capitis - Correct Answers Hepatitis A A nurse is giving change of shift report about a client who is 36 hr postoperative to another nurse. Which of the following should the nurse include? A. Daily bath given at 1000 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 Answers Pain 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 Answers Completes 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 Answers Hepatitis 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 Answers Measure 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 Answers Edema

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 Answers Hyperreflexia 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 Answers Urine 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 Answers Hold 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