Comprehensive Nursing Exam Preparation: 180 Questions and Answers, Exams of Nursing

Download Comprehensive Nursing Exam Preparation: 180 Questions and Answers and more Exams Nursing in PDF only on Docsity! [NGN] ATI RN COMPREHENSIVE 2023!!! ATI COMPREHENSIVE PREDICTOR VERSION 1 COMPLETE (180) QUESTIONS AND ANSWERS LATEST | NEW!!! 1. The nurse cares for a client diagnosed with superficial partial thickness burn. Thenurse should assign the client to a room with which client? A. A client diagnosed with Cushing’s Syndrome. B. A client Diagnosed with cellulitis of the left leg. C. A Client diagnosed with acute peritonsillar abscess. D. A client diagnosed with acute pelvic inflammatory disease.Answer: A 2. The nurse observes client care on a geriatric unit. The nurse should intervene inwhich situation? a. A student nurse assist the client out of bed toward the clients strong side. b. A student nurse assist the client to sit on the side of the bed by lifting the client’sshoulders and swinging the client’s legs over the edge of the bed. c. A student nurse assists the client to stand from a sitting position by grasping theclient’s elbows. d. Two student nurses use a draw sheet to turn a client in the bed.Answer: C Answer: C 9. The nurse cares for a client diagnosed with dehydration. The plan of care indicates the client is to drink two ounces of fluid every hour. The nurse determines the goal is met ifwhich is recorded on the intake and output (I&O) sheet for an eight-hour shift? a. 360 ml b. 160 ml c. 480 ml d. 240 ml 1 oz=30 ml; 60 oz*8= 480 mlAnswer: C 10. The nurse and LPN/LVN care for clients on a medical-surgical unit. The RN shoulddelegate which activity to the LPN/LVN? a. Follow up on the client’s report of chest and back itching two hours after starting apatient controlled analgesia pump. b. Provide instruction for the client receiving the first nicotine patch. c. Inform the health care provider of the client’s history of peptic ulcer disease priorto administration of streptokinase. d. Take the blood pressure and heart rate before administration of enalapril. Answer:D 11. The nurses care for the client diagnosed with tuberculosis. Before discontinuingairborne precautions, the nurse must confirm which? a. The tuberculin skin test is negative b. No acid-fast bacteria are in the sputum. c. The client has received anti-tuberculin medication for three days. d. The client’s temperature has returned to normal.Answer: B 12. The nurse cares for the client at 28 weeks gestation diagnosed with a complete placenta previa. The nurse determines discharge teaching is effective if the client makeswhich statement to her husband? a. I can go back to work tomorrow on a part-time basis b. I’m sorry to tell you we can’t have sexual relations c. I will still be able to have a vaginal birth d. I have to come back in 48 hours for a vaginal examAnswer: B 13. The nurse prepares the client diagnosed with myxedema for discharge. Whichaction should the nurse teach related to body temperature? a. “Alternate acetaminophen with ibuprophen every four hours for fever” b. “Take your temperature and record the results three times a day.” c. “Put on multiple layers of clothes until you fell comfortably warm.” d. “Use a heating pad during the day and electric blanket at night.”Answer: C 14. The nurse cares for clients in the labor and delivery unit. The nurse anticipateswhich client is a candidate for induction of labor? a. The client with the fetal face as the presenting part. b. The client diagnosed with preeclampsia. c. The client diagnosed with active herpes infection. d. The client experiencing late decelerations.Answer: B 15. The nurse cares for the client diagnosed with HIV. The nurse determines which goalis MOST important? a. Prevent Kaposi’s sarcoma. b. Prevent depression c. Prevent infections. d. Prevent social isolation.Answer: C 16. The nurse educator presents an in-service on acyanotic heart disease. Which is themost common symptom of this disorder that the nurse educator c. The child sits quietly reading a story about a boy who is going to have surgery whilethe nurse reviews the consent from the parents. The child sits on the parent’s lap and sucks the child’s thumb while the nurse usespuppets to demonstrate the use of the pulse oximeter. Answer: B 22. The nurse instructs the client after a total hip arthroplasty. The client will utilizewhich assistive devices in the home? Wheelchair crackles.Answer: B 24. The nurse cares for the client in active labor. The health care provider orders an oxytocin infusion. Which action should the nurse take FIRST after initiating the infusion? a.Time and record the length and strength of the contractions. b. Prepare the client for an emergency cesarean birth. c. Check the client’s perineum for bulging. d. Monitor the fetal heart rate.Answer: A a. b. A long - handled shoehorn. c. A reaching device. d. A raised toilet seat. e. A trochanter roll. f. A shower bench. Answer: B,C,D,F Note: total hip replacement is the same as arthroplasty 23. The client reports vomiting and diarrhea for three days. Which assessmentfinding does the nurse anticipate? a. Bradycardia b. Decreased blood pressure. c. Peripheral edema. d. Moist 25. The intensive care nurse cares for the client two hours after a myocardial infarctionis diagnosed. The nurse’s PRIORITY is to focus on which action? a. Relieve pain. b. Prevent embolism. c. Monitor the telemetry. d. Reduce apprehension.Answer: A 26. The home health nurse instructs the family how to “allergy- proof” their preschooler’s bedroom. The nurse determines teaching is successful if which of thefollowing is observed? a. There are mini-blinds on the windows without curtains. b. The feather pillows are enclosed in double pillowcases. c. The child’s doll collection is displayed high on a shelf.There are no pictures hung on the walls. Answer: D 27. The nurse cares for infants in the newborn nursery. Which observation requires thenurse to contact the physician? a. The Asian female, 12 hours old, has a large bluish area noted across the sacrum andleft hip. b. An African-American make, 2 hours old, has fine bi-basilar crackles. c. Uneven skin folds are noted on a the upper legs of a Mexican-American female born6 hours ago. d. The anterior fontanel of a Caucasian male born 28 hours ago is moderately firm andflat. Answer: C 28. The nurse cares for the client diagnosed with partial thickness burns to the entiretyof both arms. Using the Rule-of-Nines, the nurse estimates the injury is which percentage? a. 18% b. 29% c. 36% d. 9% Answer: A 4.5% front and 4.5 % back, whole arm 9% 29. The home care nurse visits the client diagnosed with late stage Parkinson’s disease.The client sits in a wheelchair. Which statement, if made by the caretaker, indicates to the home care nurse teaching is effective? a. “My Client should push the hips up from the wheelchair for about 10 seconds everyhour or so.” b. “My client should elevate the knees with a pillow when lying in bed.” c. “I will limit my client’s time in the wheelchair to 30 minutes each day.” d. “I will encourage my client to change position every six hours.”Answer: A 30. The home care nurse makes a visit to the client diagnosed with heart failure. Theclient reports having difficulty sleeping at times. The nurse should take which action FIRST? 36. The nurse prepares a list of delegated tasks for the nursing assistive personnel(NAP). Which task would be APPROPRIATE? a. Feed the client diagnosed with dysphagia related to a stroke b. Assist the client one day postoperatively to ambulate following knee replacement. c. Turn and reposition the client diagnosed with quadriplegia. d. Obtain vital signs for the client whose last B/P was 188/104Answer: C 37. The nurse cares for the client diagnosed with anorexia nervosa. The nurse shouldinclude which in the client’s plan of care? a. Allow as much time as needed for each meal. b. Observe client during and one hour after each meal. c. Explain the importance of an adequate diet. d. Use a random pattern for weigh assessments.Answer: B 38. The nurse cares for the client diagnosed with obsessive-compulsive personalitydisorder (OCD). Which does the nurse expect the client to demonstrate? a. Doubts, fears, and indecisiveness b. Marked emotional maturity. c. An elaborate delusional system. d. Rapid, frequent mood swings.Answer: A 39. The nurse prepares to administer medications. Which medication cannot be givendirectly intravenously? a. 50%dextrose b. Potassium chloride (KCI) c. Furosemide (Lasix) d. Calcium gluconate.Answer: B 40. The nurse cares for a client diagnosed with pancreatic cancer. When talking tothe client about the diagnosis, the nurse anticipates the client will make which statement? a. How can I have cancer when I don’t hurt anywhere on my entire body? b. I’ve been feeling fine and didn’t go to the doctor until my skin was kind of yellow. c. I should have known something was wrong when I gained 10 pounds in six weeks. d. My last couple of bowel movements have look almost black in color.Answer: B 41. The parent of an adolescent diagnosed with hemophilia calls the nurse to discussthe adolescent’s desire to participate in sports. Which activity should the nurse recommend? a. Soccer b. Gymnastics c. Swimming d. Snowboarding Answer: C 42. The nurse prepares to administer medications to the following clients. Whichmedication should the nurse pass FIRST? a. Cephalexin to the postoperative client with a white blood cell count (WBC of9.5/mm3 b. Morphine to the postoperative client reporting pain at a 5 on a 0-10 scale. c. Ipratropium to the newly-admitted client diagnosed with chronic obstructivepulmonary disease. d. Warfarin tot eh client with a prothrombin (PT) time of 16 seconds and aninternational normalized ratio (INR) of 3.5. Answer: C 43. The nurse provides discharge instructions to the client with a tube after traditionalcholecystectomy. The nurse determines teaching is effective if the client makes which statement? a. The tune can be used to administer stone dissolving medications. b. This tube will stay in for 1-2 weeks and drainage will decrease. c. If it is this with mucus or blood, I an irrigate the t-tube. d. I should milk the tube every 4 hours and record the drainage.Answer: B 44. The nurse prepares to administer digoxin for the 5-year-old child. The nurse shouldwithhold the drug and contact the physician for which finding? a. The one-time dose of furosemide is also due. b. Child has not eaten in several hours. Answer: D 52. The charge nurse has received change-of-shift report on a medical- surgical unit.Which activity can be delegated to an LPN/LVN? a. Transfuse platelets for a client. b. Change a dressing on a client with a stage IV pressure ulcer. c. Initiate discharge teaching for the client whose B/P was 88/64 an hour ago. d. Obtain vital signs on a client whose BP was 88/64 an hour ago. e. Irrigate an urinary catheter. f. Administer water through a gastrostomy tube.Answer: B,D,E,F 53. The nurse presents information about misuse of medications to the senior citizengroup. Which client response indicates a safe medication practice? a. It is okay to use someone else’s medication if it is similar to my prescription. b. If I miss a dose of medication, I should not double up on the next dose. c. Combining prescribed medicines with other the counter ones is cost- saving. d. Sometimes we have prescriptions from several doctors out of necessity. Answer: B 54. The nurse cares for the client in the emergency department. The client’s friends state the client inhaled varnish remover and passed out. The nurse notices a rash around the client’s nose and mouth, axillary temperature 97.8 degrees, pulse 66, respiration 12, blood pressure 168/88, pulse oximetry 98%. Which action should the nurse take FIRST? a.Provide oxygen 2L per nasal cannula. b. Evaluate pupillary response. c. Listen to heart sounds d. Place patient in supine position.Answer: B Increased Intracranial Pressure: opposite of shock; increase BP, decreased Pulse andDecreased Respirations. Pupils don’t respond. 55. Which indicates to the nurse that a 41-year-old woman who is 5’5’’ tall is obese? a. Waist circumference is 75 cm b. Wait to hip ratio is 0.7 c. Body mass index is 31 kg/m2 d. Weight is 124 lbs.Answer: C More than 30, more than 25 overweight. Less than 19 underweight. 56. The nurse cares for the client reporting a burning sensation and itching of theright eye. On examination, the eye is red, with watery yellow discharge. The nurse understands which is the MOST likely cause of the client’s symptoms? a. Conjunctivitis b. Foreign body in the eye c. Allergic reaction d. Corneal abrasionAnswer: A 57. The nurse cares for the infant diagnosed with hydrocephalus immediately after placement of a ventriculoperitoneal (VP) shunt. The nurse should place the infant in whichposition? a. High Fowler’s Position b. Supine lying on the non-operative side c. Supine lying on the operative side d. Elevated 30 degreesAnswer: B 58. The nurse cares for the teenager recovering from mononucleosis. The teenager is upset and reports feeling too weak to resume normal home and social activates. The friends no longer come visit, and the parent is tired of “doing everything.” Which responseby the nurse is MOST appropriate? a. Medications exist that can boost strength and endurance after mononucleosis. b. Further diagnostic testing may be necessary to determine the cause of the fatigue. c. Convalescence is lengthy and people often report fatigue for several months. d. You need to make more of an effort to participate in normal activities. Answer: C 59. The nurse cares for a client after an involuntary admission to a mental health facility due to threatening to harm self. The family asks the nurse if they can take the clienthome. Which response by the nurse is MOST appropriate? a. I will speak to the health care provider about your request. b. The client is lucky to have a loving family like you. c. The courts determine how long the client is hospitalized. d. Why do you want to take the client home?Answer: C 60. The nurse cares for the adolescent diagnosed with Hodgkin’s lymphoma. The adolescent receives nitrogen mustard, vincristine, procarbazine and prednisone. Whichadverse effect of the drugs requires early preparation of the adolescent? a. Constipation b. Retarded growth in height Answer: D 67. The nurse provides care to a client diagnosed with cirrhosis. Which is the BESTexplanation for the development of edema? a. Decreased concentration of plasma albumin. b. Decreased production of aldosterone causing sodium and water retention. c. Shunting of the blood from the portal vessels into the lower pressure vessels. d. Inadequate formation, use and storage of vitamin K.Answer: A With cirrhosis there is malnutrition, with malnutrition there is decreased albumin, withdecreased albumin there is edema. 68. Nurses working in hospital environments should follow which guideline related toeffective hand washing? a. Use a petroleum-based lotion for prevention of dryness. b. Have the water temperature as hot as tolerated. c. Clean under artificial nails prior to starting shift. d. Wash for at least fifteen seconds covering all surfaces.Answer: D 69. The nurse cares for the primigravida during the transition phase of labor. Whichis MOST important for the nurse to include in the client’s plan of care? a. Provide feedback to reduce client’s anxiety. b. Assess client’s emotional reaction to impending parenthood. c. Catheterize client is unable to void for 2 hours. d. Provide comfort measures including position changes.Answer: D 70. The nurse cares for the client diagnosed with a hearing impairment. Which isa PRIORITY action for the nurse to take? a. Talk with a raised voice. b. Utilize more hand gestures. c. Speak at a slightly slower pace. d. Use more facial expressions.Answer: C 71. The nurse cares for the newborn with a port wine stain covering the face and half the body. The nurse notes that the mother refuses to look at the newborn. Which responseby the nurse is MOST appropriate? a. Allow the mother to recover from the fatigue of delivery and then bring thenewborn to her. b. Empathetically the mother not to blame herself for the newborn’s appearance. c. Talk to the family about the situation and encourage the family to comfort the other. d. Reinforce the health care provider’s explanation of the defect and allow time for themother to discuss her fears. Answer: D 72. The nurse reviews a diet containing broiled catfish, baked green beans, a roll, a brownie, and tea. The nurse identifies this diet is most appropriate for which condition? a.Celiac disease. b. Type 1 diabetes. c. Acute pancreatitis. d. Crohn’s disease.Answer: D 73. The nurse cares for a toddler diagnosed with croup. The nurse notes the toddler’srespiratory and heart rates have increased significantly. Sub sternal and intercostal retractions are pronounced, and the child is restless. Which action should the nurse take FIRST? a. Suction the child’s airway. b. Contact the health care provider. c. Percuss the child on the back. d. Increase the oxygen flow rate.Answer: B 74. The client reports dyspnea, sever chest pain, nausea, and increased anxiety. Which lab value would cause the nurse to contact the physician? a. Creatinine kinase(CK) 155 units/L. b. Troponin T 0.9 ng/mL. c. Low-density-lipoproteins (LDL) 175 mg/dL. d. Total serum lipids 850 mg/dL.Answer: B 75. An adolescent undergoing hemodialysis tells the nurse, “My friends are all going ona big trip over spring break and I can’t go. I don’t think they’ll miss me much anyway.” Which is the BEST response by the nurse? a. I would not worry about that. You can communicate with them while they are gone. b. You must be disappointed. Describe what you are feeling right now. c. I’ve been left out of things before; you’ll feel better when the break is over. d. Why do you think they won’t miss you?Answer: B 76. The nurse cared for clients diagnosed with AIDS. The nurse recognizes which statementis true regarding therapy? 1. Pneumonia and influenza vaccines are contraindicated. 2. Protease inhibitors affect cell replication and have been successful. 82. A nurse in the pediatric clinic receives a call from a parent stating, “it looks like my 10year-old has chickenpox, but my child had the immunization”. Which response by thenurse is BEST 1. “You should keep the child home for the next week”. 2. The child will need a booster vaccine once the vesicles have disappeared”. 3. “If your child had the vaccination, it can’t be chickenpox”. 4. Give aspirin every 4 hours for fever or discomfort”.Answer#1 83. After receiving report from the evening shift charge nurse, which client should thenurse see FIRST? 1. A 69-year –old diagnosed with chronic obstructive pulmonary disease requesting asleeping pill. 2. A 52-year old client diagnosed with pancreatitis reporting abdominal pain. 3. A 67-year old client diagnosed with pneumonia with a pulse oximeter reading of88% 4. A 78 year old client diagnosed with coronary artery disease with a blood pressure of155/88. Answer#3 SAO2 95- 99% 84. A nurse in the oncology clinic receives messages from four clients. Which client shouldthe nurse see FIRST? 1. A client diagnosed with testicular cancer requests information about sperm bankingprior to starting chemotherapy. 2. A client diagnosed with non-Hodgkin’s lymphoma reports facial swelling. 3. A client diagnosed with colorectal cancer receiving chemotherapy reports tingling inthe fingers. 4. A client who had a radical neck dissection notices whitish patches in the mouth.Answer#2 ABC 85. The nurse develops a plan of care for the client diagnosed with osteoporosis. Which isthe best description on the PRIORITY goal? 1. Maintenance of body weight. 2. Improved nutritional intake. 3. Knowledge of medication side effects. 4. Prevention of falls and accidents. Answer#4 86. The nurse determines which lunch menu is the BEST choice for a patient diagnosedwith fluid volume excess? 1. Turkey on wheat bread, carrot sticks, chocolate cake, 6 oz iced tea. 2. Sit-fry rice with soy sauce, green beans, ice cream, 6 oz water. 3. Pimento cheese with crackers, grapes, cookies, 4 oz diet soda. 4. Grilled cheese sandwich, dill pickle, apple, 4 oz tomato juice.Answer#1 LOW SODIUM DIET, WATER FOLLOWS SALT 87. The nurse teaches the mother of a 3-month-old infant. When planning accidentprevention, the nurse emphasizes which goal? 1. Electric outlets will be covered with plugs. 2. All small objects will be removed from the floor. 3. Crib rails will be kept in the highest position. 4. Toxic substances will be moved from lower storage.Answer#3 88. The nurse obtains a health history for the school-age child diagnosed with asthma. It ismost important for the nurse to follow up on which statement made by the child? 1. “I use a vaporizer in my room every night”. 2. “I play football and basketball”. 3. “I live in a rural area”. 4. “I snack on fresh fruit and raw vegetables”.Answer#3 89. The nurse cares for the client just admitted to the surgical unit from recovery after atotal hip replacement. It is MOST important for the nurse to take which action? 1. Elevate the affected extremity on pillows. 2. Position the client in high Fowler’s position. 3. Place the client in Buck’s traction. 4. Position the client with the legs abducted.Answer#4 ABDUCTION SPLINTER OR TWO PILLOWS BETWEEN LEGS 90. The nurse cares for the school-age child receiving phenytoin. The nurse should observefor which known adverse effect? 1. Hyperactivity several hours after ingestion. 2. Gingival hyperplasia. 3. Flushed face within an hour of ingestion. 4. Pinpoint pupils. Answer#2 (phenytoin =Dilantin=anticonvulstant) 3. 60 year old male, 55 pounds over ideal weight. 4. 40 year old female, active alcoholic.Answer#3 100. The client after radical prostatectomy expresses concern related to ongoing urinaryincontinence. Which response by the nurse is BEST? 1. Have you been doing Kegel exercises? 2. It is important to anticipate leakage and stay close to a bathroom at all times. 3. Drinking more fluids with your meals will decrease the need to void. 4. Avoiding caffeine and alcohol may reduce bladder irritation.Answer#1 101. The client reports severe lower back pain radiating down the left leg. The client identifies the pain as 9 on a 0-10 scale and states, “It feels like I’ve been stuck with a hotpoker”. Which order should the nurse anticipate? 1. Opioid analgesic. 2. Nonsteroidal anti-inflammatory drugs. 3. Immunosupressant agent. 4. Topical nonopioid analgesic.Answer#1 102. The nurse on the pediatric unit receives report from the previous shift. Which clientshould be seen FIRST? 1. The 8 year old newly diagnosed with type 1 diabetes with a blood sugar of 285mg/dl. 2. The 2 year old diagnosed with asthma whose pulse oximeter reading is 97%. 3. The 6 year old recovering from an appendectomy with a temperature of 100.3degrees F (37.9 degrees C). 4. The 10 year old with cerebral palsy with a newly placed enteral nutritionAnswer#1 RISK FOR DKA 103. The nurse instructs the client receiving enoxaparin (LOVENOX). Which client responseindicates teaching is EFFECTIVE? 1. I will inject the medication into the far left or right side of my abdomen every day. 2. I can take ibuprofen if I am feeling pain. 3. The antidote to enoxaparin is Vitamin K. 4. I am taking enoxaparin to dissolve blood cloths.Answer#1 (ANTIDOTE: Protamine sulfate) 104. The nurse cares for the client receiving acyclovir. The nurse knows acyclovir is used totreat which condition? 1. Herpes simplex. 2. Contact dermatitis. 3. Candidiasis. 4. Psoriasi s.Answer#1 105. The nurse admits the 6-month old infant diagnosed with hypovolemia secondary to diarrhea. The physician orders KCL 1 mEq per kg/body weight in 250 ml 0.9% saline. Priorto administering the medication, which action should the nurse take FIRST? 1. Validate the baby has wet a diaper. 2. Determine the possible causes for the diarrhea. 3. Offer the electrolyte solution orally. 4. Arrange for a central line catheter placement.Answer#1 No PEE no K!!!!!! 106. The nurse cares for the client diagnosed with spinal cord injury at the level of T1. Thenurse notes the client is flushed and sweating profusely. The client reports a headache andnausea. The vital signs are blood pressure 140/98 and heart rate 38 beats per minute. Which action should the nurse take FIRST? 1. Administer antihypertensive medication. 2. Palpate the client’s bladder. 3. Position the client in a supine position. 4. Place the client on a cardiac monitor.Answer#2 ASSESS FIRST ;IPPA (she inspected and now palpate) 107. The nurse cares for the client diagnosed with HIV. The client reports difficulty copingwith the diagnosis. The nurse encourages the client to take which action? 1. Attend church services weekly. 2. Obtain a prescription or an anti-depressant medication. 3. Keep a journal recording feelings. 4. Identify successful coping mechanisms used in the past.Answer#4 115. The community nurse instructs the client receiving isoniazid. The nurse is MOSTconcerned if the client makes which statement? 1. I will not eat tuna sandwiches. 2. I will frequently wash my hands. 3. I will limit my alcohol intake to 1 beer/day. 4. I will eat small, frequent feedings. Answer#3 (alcohol increases risk for hepatotoxicity, wrong statement shouldn’t drink) 116. The nurse prepares to administer an intramuscular injection to the one- year-old infant. The infant is in the 70th percentile for height and weight. The nurse determineswhich injection site is MOST appropriate? 1. Vastus lateralis. 2. Deltoid. 3. Ventrogluteal. 4. Abdome n. Answer#1 117. The nurse plans a burn prevention program for older adults. What is the bestdescription of the cause of burns in the elderly population? 1. Frayed electrical wires. 2. Pots and pans on a stove. 3. A lighted cigarette. 4. A bathtub of hot water.Answer#2 118. Prior to administration of a cleansing enema, the nurse explains the procedure to theclient. Which statement, if made by the client to the nurse, indicates further teaching is necessary? 1. I have to lie on my right side while you put the solution in me. 2. You’ll put in about the same amount of fluid that’s in a full IV bag. 3. You want to see the returns in the toilet before I flush. 4. If I feel I can’t hold any more of the fluid, I’ll tell you to stop for a moment. Answer#1 (position on Left Sim’s position to allow the solution to flow by gravity) 119. The nurse cares for the adolescent diagnosed with asthma. Which is the MOSTappropriate response by the nurse? 1. The cause of the wheezing is the collapse of the small air sacs in your lungs. 2. There is a narrowing of airways going to your lungs. 3. The wheezing is due to fluid in the space surrounding your lungs. 4. The wheezing is due to inflammation in your nose and throat.Answer#2 120. The nurse cares for the unconscious client after a motor vehicle accident. The nursedoes a quick physical assessment and remarks, “He must have a history of chronic emphysema”. The basis for the nurse’s judgment was the presence of which finding? 1. A rounded chest and clubbing of nails. 2. Cyanosis around the patient’s mouth. 3. An ipratropium inhaler in the shirt pocket. 4. Smell of cigarette smoke on the patient’s clothes.Answer#1 121. The school nurse reviews bike safety concerns with elementary school children.Which statement indicates to the nurse teaching is effective? 1. I know my bike is the right size because I can read the pedals. 2. I can ride in the street as long as I ride on the left hand side. 3. I will use a bike helmet and wear light colored clothing when I ride. 4. I will have to buy a horn if I want to ride at night.Answer#3 122. The nurse cares for the client on an NPO status. The client repeatedly asks the nursefor something to drink. Which action by the nurse is MOST appropriate? 1. Frequently explain why fluids are restricted. 2. Offer several ice chips each time the client requests a drink. 3. Turn on the television or radio. 4. Provide oral hygiene care frequently.#4 123. The nurse cares for the client after a near-drowning experience in the Atlantic Ocean.It is MOST important for the nurse to monitor for which complication? 1. Hypernatremia. 2. Hypomagnesemia. 3. Hypocalcemia. 4. Hyperkalemia.Answer#1 124. The newly admitted client tells the nurse, “I have not had a good bowel movement in10 days”. It is MOST important for the nurse to ask which question. 1. What types of food with fiber do you eat? 2. Have you had small amounts of liquid stool? 3. Do you notice a bad odor to your breath? 4. Are you having any nausea and vomiting?Answer#2 CAN BE OBSTRUCTION OR IMPACTION 4. Schedule alternating periods of rest and activity.Answer #4 131. The client has a 2.5 centimeter abdominal aortic aneurysm (AAA) discovered on X-ray.The nurse determines which goal is MOST appropriate for the client? 1. The client will report pain of no greater than “4” on a 0-10 scale. 2. The client will return for follow-up appointments every 6 months. 3. The client will verbalize understanding of perioperative nursing care. 4. The client will limit activities to bathing, eating, dressing, and toileting.Answer#4 132. The nurse cares for the client diagnosed with diabetes insipidus. Which finding willthe nurse expect to observe? 1. Daily fluid intake of 1-2 liters. 2. Urine specific gravity of 1.050. 3. Daily urine output of 10 liter. 4. Serum sodium level of 120 mEq/L. Answer#3 (Polyuria 2 to 24 L/day, low specific gravity 0.006,) 133. The nursing supervisor observes the staff nurse’s ease and excellence in communicating with new parents and family members. The supervisor recommends the staff nurse for the position teaching childbirth classes. What component of leadership hasthe supervisor demonstrated? 1. Empowerment. 2. Charismatic leadership. 3. Compassionate leadership. 4. Shared governance.Answer#1 134. The nurse receives report for clients on a Woman’s Health Unit. Which client shouldthe nurse see FIRST? 1. The client post bladder repair reports pain is not fully relieved by medicationadministered through the PCA pump. 2. The client 6 hours after a right mastectomy reports the sheets under her torso feelwet. 3. The client 12 hours after abdominal hysterectomy with a pulse of 90 and B/P130/88. 4. The client diagnosed with pelvic inflammatory disease with an oral temperature of 101.8 degrees F (38.8 degrees C).Answer#2 135. The nurse instructs the client after a cataract extraction with a lens implant. The nursedetermines further teaching is necessary if the client makes which statement? 1. I need to make every effort to avoid sneezing, coughing, or vomiting. 2. I have to sleep with this eye shield on but can wear my glasses during the day. 3. I should call the doctor if I start seeing double or flashes of light. 4. It’s okay to bend over and pick up my grandchild if I am wearing my eye shield.Answer#4 136. The nurse cares for the client in active labor. The client reports contractions started about 3 hours ago. The contractions occur every 4-5 minutes lasting for about 1 minute. The client’s water broke about an hour ago, and the pains are getting worse. Which action should the nurse take first? 1. Administer oxygen 2 L/min by nasal cannula. 2. Place external uterine and fetal monitors on the client’s abdomen. 3. Assist the client into a high-Fowler’s position. 4. Instruct the partner to model pursed-lipped breathing.Answer#2 137. The client is scheduled for a pelvic ultrasound. Prior to the procedure it is MOSTimportant for the nurse to take which action? 1. Encourage the client to completely empty her bladder. 2. Administer a mild sedative. 3. Instruct the client to drink several glasses of water. 4. Obtain an informed consent.Answer#3 138. The nurse cares for a client diagnosed with amnesia after a motor vehicle accident. The client’s friend was killed in the accident, and the client was arrested for driving whileintoxicated and speeding. Which is the MOST likely cause of the amnesia? 1. Repression. 2. Suppression. 3. Projection. 4. Dissociatio n. Answer#4 139. The nurse teaches the parent of an infant after repair of cleft lip and palate. Which isthe BEST solution to remove dried food and drainage from the suture line? 1. Hydrogen peroxide. 2. A mild antiseptic solution. 3. Normal saline. 4. Providone-iodine solution.Answer#3 140. The nurse on a medical-surgical unit received report. Which clients should the nursesee FIRST? 145. The nurse prepared to administer buspirone 15 mg to the client. The nurse recognizedthis medication is MOST appropriate for which client? 1. The 45 year old woman diagnosed with pancreatitis reporting nausea and vomiting. 2. The 27 year old woman diagnosed with panic attacks. 3. The 60 year old man diagnosed with coronary artery disease with a blood pressureof 172/94. 4. The 38 year old man diagnosed with schizophrenia reporting auditoryhallucinations. Answer#2 Antianxiety Med 146. The nurse records the following intake of the client during an 8 hour shift: ½ liter of oral bowel prep solution (500 ml)8 ounces of juice 1 oz = 30 ml; (240 ml) 4 tablespoons of medicine through a G-tube 1 tbsp= 15 ml; (60 ml) 2 cups of water 1 cup=8 oz= 16 oz; (480 ml) 0.9% sodium chloride at 125 ml/hour IV 125*8= (1000 ml) Recordthe patient’s intake in milliliters (ML) 2280 ML 147. The nurse cares for the unconscious client diagnosed with a closed head injury. Thereis no family present. What is the MOST appropriate action for the nurse to take? 1. Wait until a family member is contacted before treating the client. 2. Request the attending health care provider to sign the consent form. 3. Begin treatment on the client under the doctrine of implied emergency consent. 4. Delegate the unit secretary to call every number listed on the client’s cell phone.Answer#3 148. The nurse and nursing assistive personnel (NAP) care for clients in the postpartumunit. The nurse appropriately delegated which tasks to the NAP? Select all that apply. 1. Document the amount of food intake at lunch. 2. Assist the father dress a newborn prior to a photograph. 3. Perform an intermittent bladder catheterization. 4. Speak to the health care provider about the results of a client’s complete bloodcount. 5. Ambulate the mother after cesarean birth to the bathroom. 6. Obtain the vital signs on the client ready for discharge.# 1,2,5,6 149. The nurse cares for the child diagnosed with a closed head injury. It is most importantfor the nurse to assess which finding? 1. The child’s response to the environment. 2. The child’s intake and output. 3. The child’s vital signs. 4. The child’s motor activity. Answer#1 (level of consciousness) 150. The staff nurse asks for the goals of the Quality Assurance Committee. Which is anexample of a goal? 1. Use of an alternate laundry service. 2. Explore an increase of handicap parking spaces. 3. Survey documentation of follow-up after administration of pain medication. 4. Determine the cause for employee’s tardiness.Answer#3