RN COMPREHENSIVE PREDICTOR 2019 FORM A 180 EXAM QUESTIONS AND CORRECT ANSWERS | LATEST ED, Exams of Nursing

Download RN COMPREHENSIVE PREDICTOR 2019 FORM A 180 EXAM QUESTIONS AND CORRECT ANSWERS | LATEST ED and more Exams Nursing in PDF only on Docsity! RN COMPREHENSIVE PREDICTOR 2019 FORM A 180 EXAM QUESTIONS AND CORRECT ANSWERS | LATEST EDITION 2024 | PROFESSOR VERIFIED | ALREADY GRADED A+ A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following actions should the nurse take? A. Request a renewal of the prescription every 8 hr. B. Check the client's peripheral pulse rate every 30 min C. Obtain a prescription for restraint within 4 hr. d. Document the client's condition every 15 minutes. ------CORRECT ANSWER------------ -d. Document the client's condition every 15 minutes. A nurse is caring for a client who has end-stage kidney disease. The client's adult child asks the nurse about becoming a living kidney donor for her father. Which of the following condition in the child's medical history should the nurse identify as a contraindication to the procedure? A. Amputation B. Osteoarthritis C. Hypertension D. Primary glaucoma ------CORRECT ANSWER-------------C. Hypertension A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the postpartum unit due to a staffing shortage for the shift. Which of the following client should the nurse delegate to the LPN? A. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs. B. A client who sustained a concussion and has unequal pupils. C. A client who is postoperative following a bowel resection with an NG tube set to continuous suction. D. A client who fractured his femur yesterday and is experiencing shortness of breath. -- ----CORRECT ANSWER-------------C. A client who is postoperative following a bowel resection with an NG tube set to continuous suction. A nurse is working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of no blanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan? A. Place the client upright on a donut-shaped cushion B. Teach the client to shift his weight every 15 min while sitting C. Turn and reposition the client every 3 hr while in bed D. Assess pressure points every ------CORRECT ANSWER-------------B. Teach the client to shift his weight every 15 min while sitting A nurse is caring for a client who is dilated to 10 cm and pushing. Which of the following pain-management is a safe option for the client? E. Naloxone hydrochloride. F. Spinal anesthesia. G. Pudendal block. H. Butorphanol tartrate. ------CORRECT ANSWER-------------G. Pudendal block. A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? a. Teach the client to scan the right to see objects on the right side of her body. b. Place the bedside table on the right side of the bed. c. Orient the client to the food on her plate using the clock method. d. Place the wheelchair on the client's left side. ------CORRECT ANSWER-------------b. Place the bedside table on the right side of the bed. A nurse is assessing a client who has major depressive disorder. Which of the following findings should the nurse identify as the suicidal? A. The client changes the subject when future plans are mentioned. B. The client talks about being in pain constantly. A nurse is providing discharge teaching for a client who has an implantable cardioverter defibrillator which of the following statements demonstrates understanding of the teaching? A. "I will soak in the tub rather and showering" B. "I will wear loose clothing around my ICD" C. "I will stop using my microwave oven at home because of my ICD" D. "I can hold my cellphone on the same side of my body as the ICD" ------CORRECT ANSWER-------------B. "I will wear loose clothing around my ICD" A nurse is caring for a client who is at 14 weeks gestation and reports feelings of ambivalence about being pregnant. Which of the following responses should the nurse make? A. "Describe your feelings to me about being pregnant" B. "You should discuss your feelings about being pregnant with your provider" C. "Have you discussed these feelings with your partner?" D. "When did you start having these feelings?" ------CORRECT ANSWER-------------A. "Describe your feelings to me about being pregnant" A nurse is planning care for a client who has a prescription for a bowel- training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care? A. Encourage a maximum fluid intake of 1,500 ml per day. B. Increase the amount of refined grains in the client's diet. C. Provide the client with a cold drink prior to defecation. D. Administer a rectal suppository 30 minutes prior to scheduled defecation times. ------ CORRECT ANSWER-------------D. Administer a rectal suppository 30 minutes prior to scheduled defecation times. A nurse is caring for a client who is in active labor and requests pain management. Which of the following actions should the nurse take? A. Administer ondansetron. B. Place the client in a warm shower. C. Apply fundal pressure during contractions. D. Assist the client to a supine position. ------CORRECT ANSWER-------------B. Place the client in a warm shower. A nurse in an emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority? A. Below-the knee amputation B. Fractured tibia C. 95% full-thickness body burn D. 10cm (4in) laceration to the forearm ------CORRECT ANSWER-------------A. Below- the knee amputation a nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include? A. Remove the client's restraint every 4hr B. Document the client's condition every 15 min C. Attach the restrain to the bed's side rails D. Request a PRN restrain prescription for clients who are aggressive ------CORRECT ANSWER-------------B. Document the client's condition every 15 min A nurse is teaching an in-service about nursing leadership. Which of the following information should the nurse include about an effective leader? A. Acts as an advocate for the nursing unit. B. (Unable to read) for the unit C. Priorities staff request over client needs. D. Provides routine client care and documentation. ------CORRECT ANSWER------------- A. Acts as an advocate for the nursing unit. A nurse is reviewing the laboratory findings of a client who has and reports that she has been following her care. The nurse should identify which of the following findings indicates a need to revise the client's plan of care. A. Serum sodium 144 mEq/ B. (Unable to read) C. Hba1c 10 % D. Random serum glucose 190 mg/dl. ------CORRECT ANSWER-------------C. Hba1c 10 % A nurse in a provider's office is reviewing the laboratory results of a group of clients. The nurse should identify that which of the following sexually transmitted infections is a nationally notifiable infectious disease that should be reported to the state health department? A. Chlamydia B. Human papillomavirus C. Candidiasis D. Herps simplex virus ------CORRECT ANSWER-------------A. Chlamydia A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. Which of the following group facilitation techniques should the nurse include in the teaching? A. Share personal opinions to help influence the group's values B. Measure the accomplishments of the group against a previous group C. Yield in situations of conflicts to maintain group harmony D. Use modeling to help the clients improve their interpersonal skills ------CORRECT ANSWER-------------D. Use modeling to help the clients improve their interpersonal skills A nurse is planning for a client who practices Orthodox Judaism. The client tells the nurse that its Passover holiday. Which of the following action should the nurse include in the plan of care? A. Provide chicken with cream sauce. B. Avoid serving fish with fins and scales. C. Provide unleavened bread. D. Avoid serving foods containing lamb. ------CORRECT ANSWER-------------C. Provide unleavened bread. A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the effectiveness of the treatment: A. A chest x-ray reveals increased density in all fields. B. The client reports feeling less anxious. C. Diminished breath sounds are auscultated bilaterally D. ABG results include Ph 7.48 PaO2 77 mm Hg and PaCO2 47 mm Hg. ------ CORRECT ANSWER-------------B. The client reports feeling less anxious. A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse include? A. Critical pathways have unlimited timeframe for completion B. aimed to decrease health care costs. C. (Unable to read) critical pathway if variances (Unable to read) D. (Unable to read) are used to create the critical pathway. ------CORRECT ANSWER--- ----------B. aimed to decrease health care costs. A nurse is reviewing the medical record of a client who has schizophrenia. Which of the following should the nurse report to the provider? Exhibit 1 Blood pressure: 102/56 mm Hg. Heart rate: 95/min Respiratory rate: 18/min Temperature: 37.4C (99.3F) Exhibit 2 Medication Administration Record Clozapine 150 mg PO twice daily Benztropine 0.5 mg PO twice daily as needed for tremors. Exhibit 3 Nurse's notes: Client reports feeling dizzy when changing positions, Reports weight gain of 1kg (2.2 lb.) in the past month. Also reports a sore throat for the past 3 days and dry mouth. Client ate 75% of breakfast and reports slightly nauseous. A. Dietary intake B. Heart rate. C. Sore throat. D. Blood pressure ------CORRECT ANSWER-------------C. Sore throat. A charge nurse is educating a group of unit nurses about delegating client tasks to assistive personnel A. "The nurse is legally responsible for the actions of the AP". B. "An AP can perform tasks outside of his range if he has been trained". C. "An experienced AP can delegate to another AP". D. "An RN evaluates the client needs to determine tasks to delegate ------CORRECT ANSWER-------------D. "An RN evaluates the client needs to determine tasks to delegate A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider? A. Contractions lasting 80 seconds B. FHR baseline 170/min C. Early decelerations in the FHR C. Temperature 37.4C (99.3) ------CORRECT ANSWER-------------B. FHR baseline 170/min A nurse working in a rehabilitation facility is developing a discharge plan for a client who has left-sided hemiplegia. Which of the following actions is the nurse's priority? A. Consult with a case manager about insurance coverage. B. Counsel caregivers about respite care options. C. Ensure that the client has a referral for physical therapy. D. Refer the client to a local stroke support group. ------CORRECT ANSWER------------- C. Ensure that the client has a referral for physical therapy. A nurse in a mental health unit is planning room assignments for four clients. Which of the following client should be closest to the nurse's station? A. A client who has an anxiety disorder and is experiencing moderate anxiety. B. A client who has somatic symptom disorder and reports chronic pain. C. A client who has depressive disorder and reports feeling hopeless. D. A client who has bipolar disorder and impaired social interactions. ------CORRECT ANSWER-------------C. A client who has depressive disorder and reports feeling hopeless. A nurse is preparing to measure a temperature of an infant. Which of the following action should the nurse take? A. Place the tip of the thermometer under the center of the infant's axilla. B. Pull the pinna of the infant's ear forward before inserting the probe. -down and back C. Insert the probe 3.8 cm (1.5in) into the infant's rectum. D. Insert the thermometer in front of the infant's tongue. ------CORRECT ANSWER------- ------A. Place the tip of the thermometer under the center of the infant's axilla. A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan? A. Encourage the client to spend time in the day room B. Withdraw the client's TV privileges is the does not attend group therapy C. Encourage the client to take frequent rest periods D. Place the client in seclusion when he exhibits signs of anxiety ------CORRECT ANSWER-------------C. Encourage the client to take frequent rest periods A nurse is admitting medications to a group of clients. Which of the following occurrences requires the completion of an incident report? A. A client receives his antibiotics 2hr late B. A client vomits within 20min of taking his morning medications C. A client requests his statin to be administered at 2100 D. A client asks for pain medication 1hr early ------CORRECT ANSWER-------------A. "Does the doctor know you are eating that?" A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching? A. Leaving a nasogastric tube clamped after administering oral medication B. Documenting communication with a provider in the progress notes of the client's medical records C. Administering potassium via IV bolus D. Placing a yellow bracelet on a client who is at risk for falls ------CORRECT ANSWER- ------------C. Administering potassium via IV bolus A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching? A. Establish a toileting schedule for the client B. Use clothing with buttons and sippers C. Discourage physical activity during the day D. Engage the client in activities that increase sensory stimulation ------CORRECT ANSWER-------------A. Establish a toileting schedule for the client The nurse is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client's history is a contradiction to the use of oral contraceptives? A. Hyperthyroidism. B. Thrombophlebitis. C. Diverticulosis. A nurse is providing care for a group of clients. Which of the following client's should the nurse identify as having the highest risk for developing a pressure injury? A. A client who has a T-tube following an open cholecystectomy. B. A client who had a knee 2 days ago following a sports injury. C. A client who has dementia and is incontinent of urine and feces D. A client who has a myocardial infarction and is receiving thrombolytic therapy. ------ CORRECT ANSWER-------------C. A client who has dementia and is incontinent of urine and feces A nurse is teaching a client who has glaucoma and a new prescription for timolol eyedrops. Which of the following statements indicates an understanding of the teaching? A. "I will place the eye drops in the center of my eye" B. "I will place pressure on the corner of my eye after using the eye drops" C. "I should expect my tears to turn a red color after using the eye drops." D. "I should expect the eye drops to appear cloudy." ------CORRECT ANSWER------------ -B. "I will place pressure on the corner of my eye after using the eye drops" A nurse is providing teaching to a client who is 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? A. Bleeding gums B. Faintness upon rising C. Swelling of the face D. Urinary frequency ------CORRECT ANSWER-------------C. Swelling of the face A nurse is caring for a client who has a diagnosis of stage IV metastatic cancer. Which of the following responses should the nurse make? A. "I would recommend sharing your feelings with a psychologist". B. "I can give you information about making end of life decisions". C. "You should discuss your end life decisions with your family" D. "Everyone feels this way at first. You will start feeling better soon". ------CORRECT ANSWER-------------B. "I can give you information about making end of life decisions". A nurse is caring for a client wo has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take? A. Keep client's calcium gluconate at the client's bedside B. Monitor blood pressure every 2 hr. C. Remove IV bag from exposure to light. D. Attach tan inline filter to the IV tubing. ------CORRECT ANSWER-------------C. Remove IV bag from exposure to light. A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect? A. Feelings of dread B. Heightened perceptual field C. Rapid speech D. Purposeless activity ------CORRECT ANSWER-------------B. Heightened perceptual field A nurse is reviewing the laboratory report of a client who has been having lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect? A. Withhold the next dose. B. Increase the dosage. C. Discontinue the medication. D. Administer the medication ------CORRECT ANSWER-------------D. Administer the medication A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? A. Stay in bed at least 1hr if unable to fall asleep B. Take 1 hr nap during the day C. Perform exercise prior to bed D. Eat a light snack before bedtime ------CORRECT ANSWER-------------D. Eat a light snack before bedtime A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer? A. Pregabalin B. Lorazepam C. Colchicine D. Codeine ------CORRECT ANSWER-------------A. Pregabalin A nurse is caring for a client following insertion of a chest tube 12 hr. ago. Which following actions should the nurse take? A. Assess the amount of drainage in the collection chamber. B. Clamp the chest tube during ambulation. C. Report continuous bubbling in the water seal chamber. D. Strip the chest tube every 4 hr. to maintain patency. ------CORRECT ANSWER-------- -----C. Report continuous bubbling in the water seal chamber. A nurse is caring for a client who is receiving morphine 4 mg via IV bolus every 4 hr. PRN. The nurse should monitor for which of the following adverse effects? A. Productive cough. B. Urinary retention. C. Rhinitis D. Fever. ------CORRECT ANSWER-------------B. Urinary retention. A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states "I don't know what to do. Everything has been happening so quickly." Which of the following by the nurse is therapeutic? A. "Can you talk about what happens with your partner at home?" B. "Why do you think your partner's symptoms are progressing so quickly?" C. "You should make sure your partner takes the prescribed medication." D. "You did the right thing by bringing your partner in for treatment." ------CORRECT ANSWER-------------A. "Can you talk about what happens with your partner at home?" . A nurse is providing dietary teaching to a guardian of a preschooler who has a new diagnosis of celiac disease. Which of the following statements by the guardian indicates an understanding of the teaching? D. "I will inform a client that his family should help make his health care decisions." ------ CORRECT ANSWER-------------B. "I will intervene if there is conflict between a client and his provider" A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take? A. Raise the side rails on both sides of the client's bed during repositioning. B. Reposition the client without assistive devices. C. Discuss the client's preferences for determining a reposition schedule. D. Evaluate the client's ability to help with repositioning. ------CORRECT ANSWER------- ------D. Evaluate the client's ability to help with repositioning. A nurse is orientation a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates and understanding of PSV? A. "It keeps the alveoli open and prevents atelectasis." B. "It allows preset pressure delivered during spontaneous ventilation." C. "It guarantees minimal minute ventilator." D. "It delivers a preset ventilatory rate and tidal volume to the client ------CORRECT ANSWER-------------B. "It allows preset pressure delivered during spontaneous ventilation." A nurse is caring for an infant who has coaction of the aorta. Which of the following should the nurse identify as an expected finding? A. Weak femoral pulses B. Frequent nosebleeds C. Upper extremity hypotension D. Increased intracranial pressure\ ------CORRECT ANSWER-------------A. Weak femoral pulses A nurse is auscultating for crackles on a client who has pneumonia. Which of the following anterior chest wall locations should the nurse auscultate? ------CORRECT ANSWER-------------- Auscultate Lower Lobes A nurse is assisting with the development of an informed document for participation in a research study. Which of the following information should the nurse include? A. A statement that participants can leave the study at will. B. An assignment of the participant to either the experimental or control group. C. A list of the clients participating in the study. D. A description of the framework the researchers will use to evaluate the data. ------ CORRECT ANSWER-------------A. A statement that participants can leave the study at will. A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include? A. Excessive sweating B. Increased urinary frequency C. Dry cough D. Metallic taste in mouth ------CORRECT ANSWER-------------Excessive sweating A nurse is caring for a client who has a new temporary synchronous pacemaker. Which of the following should the nurse report to the provider? A. The client's pulse oximetry level is 96%. B. (Unable to read) C. The client develops hiccups. D. The ECG shows pacing spikes after the QRS complex. ------CORRECT ANSWER---- ---------C. The client develops hiccups. A nurse is preparing discharge information for a client who has type 2 diabetes mellitus. Which of the following resources should the nurse provide to the client? A. Personal blogs about managing the adverse effects of diabetes medications B. Food label recommendations from the Institute of Medicine C. Diabetes medication information from the Physicians' Desk Reference D. Food exchange lists for meal planning from the American Diabetes Association ------ CORRECT ANSWER-------------D. Food exchange lists for meal planning from the American Diabetes Association . A nurse is providing teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching? A. "The PCA will deliver a double dose of medication when you push the button twice." B. "You can adjust the amount of pain medication you receive by pushing on the keypad." C. "Continuous PCA infusion is designed to allow fluctuating plasma medication levels." D. "You should push the button before physical activity to allow maximum pain control." ------CORRECT ANSWER-------------D. "You should push the button before physical activity to allow maximum pain control." A nurse is caring for a client who has diabetes mellitus and is receiving long-acting insulin for blood glucose management. The nurse should anticipate administering which of the following types of insulin? E. Glargine insulin. F. Regular insulin. G. NPH insulin. H. Insulin aspart. ------CORRECT ANSWER-------------E. Glargine insulin. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following should the toddler participate? A. Looking at alphabet flashcards. B. Playing with a large plastic truck. C. Use scissors cut out paper shapes. D. Watching a cartoon in the dayroom. ------CORRECT ANSWER-------------B. Playing with a large plastic truck. A nurse is caring for a client who is receiving intermittent feedings via a feeding pump and is experiencing dumping syndrome. Which of the following actions should the nurse take? A. Administer a refrigerated feeding. B. Increased the amount of water use to flush the tubing. C. Monitor the rate of the client's feedings. D. Instruct the client to move onto their right side. ------CORRECT ANSWER-------------C. Monitor the rate of the client's feedings. A. Periorbital edema. B. Decreased frequency of urination. C. Enuresis. D. Diarrhea. ------CORRECT ANSWER-------------C. Enuresis. A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? A. A client who has COPD and a respiratory rate of 44/min B. A client who has cancer with a sealed implant for radiation therapy C. A client who is receiving heparin for deep-vein thrombosis D. A client who is 1 day postoperative following a vertebroplasty ------CORRECT ANSWER-------------D. A client who is 1 day postoperative following a vertebroplasty A nurse is preparing to administer dopamine hydrochloride 4 mcg/kg/min via continuous infusion. Available is dopamine hydrochloride in a solution of 800 mg in a 250 ml bag. The client weighs 80 kg. The nurses should set the IV infusion to deliver how many mL/hr? (Round the answer to the nearest whole number) ------CORRECT ANSWER-------------6 mL/hr A nurse is providing teaching to the parents of a newborn genetic screening. Which of the following statement should the nurse include in the teaching? A. "This test should be performed after your baby is 24 hours old." B. "A nurse will draw blood from your baby's inner elbow." C. "Your baby will be given 2 ounces of water to drink prior to the test." D. "This test will be repeated when your baby is 2 months old." ------CORRECT ANSWER-------------A. "This test should be performed after your baby is 24 hours old." A nurse is providing discharge teaching to a client who is postoperative following a colon resection and has a new ascending colostomy. Which of the following statements by the client indicates an understanding of the teaching? A. "My stool will become fully formed within 3 weeks" B. "My skin will need to be cleaned with alcohol before I apply a new pouch" C. "I should avoid eating popcorn and fresh pineapple" D. "I should expect bruising around the stoma" ------CORRECT ANSWER-------------C. "I should avoid eating popcorn and fresh pineapple" 98. A nurse is admitting a client who had a stroke and exhibits facial drooping, drooling and hoarseness. Which of the following is the nurse's priority? A. Refer the client to a speech language pathologist. B. Monitor the client's prealbumin levels C. Measure the client's weight. D. Place the client on NPO status. ------CORRECT ANSWER-------------A. Refer the client to a speech language pathologist. PERO D. Place the client on NPO status.?????????????????? I THINK IS THI ONE- RISK FOR ASPIRATION A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make? A. "Taking furosemide can cause your potassium levels to be high" B. "Eat foods that are high in sodium" C. "Rise slowly when getting out of bed" D. "Taking furosemide can cause you to be overhydrated" ------CORRECT ANSWER---- ---------C. "Rise slowly when getting out of bed" A nurse is planning a teaching session for a client who is postoperative following a colon resection. Which of the following actions should the nurse take first? A. Providing written material for the client to read B. Plan a short instruction about coughing and deep breathing. C. Determine the client's current pain level. D. Instruct the client about dietary restrictions. ------CORRECT ANSWER-------------C. Determine the client's current pain level. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary recommendations should the nurse make? A. Coffee with creamer. B. Lettuce with sliced avocados. C. Broiled skinless chicken breast with brown rice. D. Warm toast with margarine. ------CORRECT ANSWER-------------C. Broiled skinless chicken breast with brown rice. A nurse is caring for a client who asks for information regarding organ donation. Which of the following should the nurse make? A. "I cannot be a witness for your consent to donate." B. "Your name cannot be removed once you are listed on the organ donor list." C. "Your desire to be an organ donor must be documented in writing." D. "You must be at least 21 years of age to become an organ donor." ------CORRECT ANSWER-------------C. "Your desire to be an organ donor must be documented in writing." A nurse is teaching a female client about personal hygiene. Which of the client actions indicates an understanding go the teaching? A. The client takes a hot bubble bath every day. B. The client wipes back to front when toileting. C. The client washes her perineum first when bathing. D. The client brushes her teeth twice daily. ------CORRECT ANSWER-------------D. The client brushes her teeth twice daily. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take? A. Obtain the newborn's body temperature using a tympanic thermometer. B. (Unable to read) FACES pain scale. C. Auscultate the newborn's apical pulse for 60 seconds. D. Measure the newborn's head circumference over the eyebrows and below the occipital prominence. ------CORRECT ANSWER-------------C. Auscultate the newborn's apical pulse for 60 seconds. E. Clarify the reason for the referral with the provider's office. ------CORRECT ANSWER-------------E C A B D (My choice) A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for paternal fluid therapy. The guardian asks. "What are the indications that my baby needs an IV?" Which of the following responses should the nurse make? A. "Your baby needs an IV because she is not producing any tears" B. "Your baby needs an IV because her fontanels are budging" C. "Your baby needs an IV because she is breathing slower than normal" D. "Your baby needs an IV because her heart rate is decreasing" ------CORRECT ANSWER-------------A. "Your baby needs an IV because she is not producing any tears" A nurse is caring for a client who is receiving intermittent eternal tube feeding. Which of the following places the client at risk for aspiration? A. A residual of 65mL 1 hr postprandial B. A History of gastroesophageal reflux disease C. Sitting in a high-Fowler's position during the feeding D. Receiving a high osmolarity formula ------CORRECT ANSWER-------------B. A History of gastroesophageal reflux disease A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching? A. Take magnesium hydroxide for indigestion B. Drink at least 3L of fluid daily C. Eat 1g/kg of protein per day D. Consume foods high in potassium ------CORRECT ANSWER-------------C. Eat 1g/kg of protein per day A nurse on a telemetry unit is assessing a client who is receiving continuous cardiac monitoring. The client's heart rate is 69/min and the PR interval is 0.24 seconds. The nurse should interpret this finding as which of the following cardiac rhythms? A. First degree AV block B. Premature ventricular contraction. C. Sinus bradycardia. D. Atrial fibrillation. ------CORRECT ANSWER-------------no answer A nurse is supervising an assistive personnel (AP) who is feeding a client. The nurse observes that the client coughs after each bite. After asking the AP to stop feeding the client, which of the following actions should the nurse take next? A. Provide the client with an instructional handout about swallowing exercises. B. Ask a speech therapist to evaluate the client's ability to swallow. C. Discuss the manifestations of impaired swallowing with the AP. D. Listens to the client's lung sounds. ------CORRECT ANSWER-------------D. Listens to the client's lung sounds. A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan? A. Ask the client directly what he is hearing B. Encourage the client to lie down in a quiet room C. Avoid eye contact with the client D. Refer to the hallucinations as if the are real ------CORRECT ANSWER-------------A. Ask the client directly what he is hearing The nurse is teaching a group of clients at a community health fair about genetic disease. Which of the following statements by a client indicates an understanding of the teaching? A. "If there is a genetic risk for future pregnancies, we can get treatment now to prevent the disease" B. "There is no need to have genetic counseling if I know that I have a family history of mental illness." C. "My family has genetic risk for breast cancer, so I am considering a total mastectomy" D. "Even if I have a genetic risk for a disease the chance, I will get the disease is probably low due to current medical treatments." ------CORRECT ANSWER-------------C. "My family has genetic risk for breast cancer, so I am considering a total mastectomy" A nurse is planning discharge teaching about cord care for the parents of a newborn. Which of the following instructions should the nurse plan to include in the teaching? A. "The cord stump will fall off in 5 days." B. "Contact the provider if the cord stump turns black." C. "Clean the base of the cord with hydrogen peroxide daily." D. "Keep the cord stump dry until it falls off." ------CORRECT ANSWER-------------D. "Keep the cord stump dry until it falls off." A nurse is providing teaching to a client who is on glucocorticoid therapy. Which of the following statements by the client indicates an understanding of the teaching? A. "I have my eyes examines annually" B. "I take a calcium vitamin supplement daily" C. "I limit my intake of foods with potassium" D. "I constantly take my medication between 8 and 9 each evening" ------CORRECT ANSWER-------------B. "I take a calcium vitamin supplement daily" A nurse is teaching a newly licensed nurse about ergonomic principles. Which of the following actions by a newly licensed nurse indicates an understanding of the teaching? A. Stands with feet together when lifting a client up in bed. B. Raises the client's head of bed before pulling the cline up. C. Uses a mechanical lift to move client from bed to chair. D. Places a gait belt around the client's upper chest before assisting a client to stand. --- ---CORRECT ANSWER-------------C. Uses a mechanical lift to move client from bed to chair. A client is requesting information from a nurse about a nitrazine test. Which of the following statements should the nurse make? A. "Your bladder should be full prior to me performing this test B. "If this test is positive you will be required to have a non-stress test. C. "This test will determine if there is leaking amniotic fluid" D. "I will be taking a blood sample to test for changes in your hormones levels" ------ CORRECT ANSWER-------------C. "This test will determine if there is leaking amniotic fluid" A nurse is completing an incident report after a client fall. Which of the following competencies of Quality and Safety Education for Nurse is the use demonstrating? A. Quality improvement. B. Patient (Unable to read) C. Evidence based practice. D. Informatics. ------CORRECT ANSWER-------------A. Quality improvement. A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of the following actions should the nurse take? A. Confront the nurse about the suspected alcohol use. B. Inform another nurse on the unit about the suspected alcohol use. C. Ask the nurse to finish administering medications and then go home. D. Notify the nursing manager about the suspected alcohol use. ------CORRECT ANSWER-------------D. Notify the nursing manager about the suspected alcohol use. A charge nurse is teaching new staff members about factors that increase a client's risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence? A. Previous violent behavior B. A history of being in prison C. Experiencing delusions D. Male gender ------CORRECT ANSWER-------------A. Previous violent behavior A charge nurse is teaching a newly licensed nurse about medication administration. Which of the following information should the charge nurse include? A. Inform clients about the action of each medication prior to administration. B. (Unable to read) two times prior to administration. C. Complete an incident report if a client vomits after taking a medication. D. Avoid preparing medications for more than two clients at one time. ------CORRECT ANSWER-------------D. Avoid preparing medications for more than two clients at one time. A charge nurse is evaluating the time management skills of a newly licensed nurse. For which of the following actions by the newly licensed nurse should the charge nurse intervene? A. Takes assigned breaks at regular intervals B. Documents the clients care tasks at the end of the shift. C. assisting with ADLs to perform time sensitive activities D. Gather necessary supplies before beginning a dressing change. ------CORRECT ANSWER-------------B. Documents the clients care tasks at the end of the shift. A nurse is caring for a client who has diaper dermatitis. Which of the following actions should the nurse take? A. Apply zinc oxide ointment to the irritated area. B. (Unable to read) C. Wipe stool from the skin using store bought baby wipes. D. Apply talcum powder to the irritated area. ------CORRECT ANSWER-------------A. Apply zinc oxide ointment to the irritated area. A nurse is assessing a client who had an uncomplicated vaginal birth 3 days ago. In which of the following locations should the nurse expect to palpate the client's fundus? - -----CORRECT ANSWER-------------C A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? A. "The client might act seductively." B. "The client is overly concentrated about minor details." C. "The client exhibits impulsive behaviors." D. "The client is exceptionally clingy to others." ------CORRECT ANSWER-------------C. "The client exhibits impulsive behaviors." A nurse is caring for a client who has a prescription for warfarin. When reviewing the client's current medications, which of the following medications should the nurse identify as contraindicated for use with warfarin? (Select all that apply) A. Aspirin B. Magnesium sulfate C. Gingko biloba. D. Cetirizine E. Ibuprofen. ------CORRECT ANSWER-------------A. Aspirin C. Gingko biloba. E. Ibuprofen. A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect? A. Ritual behavior B. Suspicious of others C. Exhibits separation anxiety D. Preoccupied with aging ------CORRECT ANSWER-------------D. Preoccupied with aging A nurse is calculating the body mass index (BMI) of a client who weighs 75 kg (165.3 lb) and is 1.8 m (5 ft 9 in) tall. The nurse should calculate the client's BMI value as which of the following? A. 23 B. 42 C. 32 D. 8 ------CORRECT ANSWER-------------A. 23 A nurse is assessing a preschooler who has recently experienced an unexpected death in the family. Which of the following should the nurse recognize as an expected finding? A. The child expresses curiosity about the death process. B. The child refuses to talk about death. C. The child believes the person will return. D. The child focuses on his own mortality. ------CORRECT ANSWER-------------C. The child believes the person will return. A nurse is assessing a client in the emergency department. Which of the following actions should the nurse take first? Exhibit 1 Laboratory Results Cerebrospinal fluid WBC 2,000/mm3 Neutrophils 88% Protein 320 mg/dl Glucose 35 mg/dl Cloudy in appearance C. "I can remove my baby's identification band as long as she is in my room" D. "I can leave my baby in my room while I walk in the hallway" ------CORRECT ANSWER-------------B. "I will not publish public announcement about my baby's birth" A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? A. Restrict the client's total fluid intake to 250 mL/hr B. Give the protamine if signs of magnesium sulfate toxicity occur C. Monitor the FHR via Doppler every 30min D. Measure the client's urine output every hour ------CORRECT ANSWER-------------D. Measure the client's urine output every hour A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record? A. "Morphine 3 mg SQ every 4 hr. PRN for pain." B. "Morphine 3 mg Subcutaneous (Unable to read) C. "Morphine 3.0 mg sub q every 4 hr. PRN for pain." D. "Morphine 3 mg SC q 4 hr. PRN for pain." ------CORRECT ANSWER-------------B. "Morphine 3 mg Subcutaneous (Unable to read) A nurse is assessing a client who has acute kidney injury and a respiratory rate of 34/min. The client's ABG results are ph. 7.28 HCO3 18 mEq/L. (Unable to read) PaO2 90 mm Hg. Which of the following conditions should the nurse expect? A. Metabolic acidosis. B. Metabolic alkalosis. C. Respiratory acidosis. D. Respiratory alkalosis. ------CORRECT ANSWER-------------A. Metabolic acidosis. A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first? A. Notify the provider. B. Report the incident to the nurse manager. C. Monitor vital signs. D. Fill out an incident report. ------CORRECT ANSWER-------------C. Monitor vital signs. A nurse received a telephone call from a parent reporting that their school-age child has a nosebleed and that they cannot stop the bleeding. Which of the following instructions should the nurse provide to the provider? A. "Have your child lie down and turn their head to their side for 10 minutes" B. "Use your thumb and forefinger to apply pressure to the (Unable to read) of your child's nose" C. "Place a warm wet washcloth over your child's forehead and the bridge of their nose" D. "Tell your child to blow their nose gently and then sit down and tilt your head back" --- ---CORRECT ANSWER-------------B. "Use your thumb and forefinger to apply pressure to the (Unable to read) of your child's A nurse is preparing to administer an autologous blood product to a client. Which of the following actions should the nurse take to identify the client? A. Match the client's blood type with the type and cross match specimens. B. Confirm the provider's prescription matches the number on the blood component. C. Ask the client to state the blood type and the date of their last blood donation. D. Ensure that the client's identification band matches the number on the blood unit. ----- -CORRECT ANSWER-------------D. Ensure that the client's identification band matches the number on the blood unit. A nurse is transcribing new medication prescriptions for a group of clients. For which of the following prescriptions should the nurse contact the provider for clarifications? A. Zolpidem 10mg PO one tablet at bedtime B. Hydrochlorothiazide 12.5 mg PO BID C. Triamcinolone acetonide 100 mcg/inhalation two puffs TID D. Lorazepam .5mg PO one tablet daily ------CORRECT ANSWER-------------D. Lorazepam .5mg PO one tablet daily A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take? A. Offer fluids every 2hr. B. Document the client's behavior prior to being placed in seclusion. C. Discuss with the client his inappropriate behavior prior to seclusion. D. Assess the client's behavior once every hour. ------CORRECT ANSWER-------------A. Offer fluids every 2hr. A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make? A. "Dehydration is treated with calcium supplements" B. "Dehydration can increase the risk of preterm labor" C. "Dehydration associated gastroesophageal reflux D. "Dehydration is caused by a decreased hemoglobin and hematocrit" ------CORRECT ANSWER-------------B. "Dehydration can increase the risk of preterm labor" A nurse is using an IV pump for a newly admitted client. Which of the following actions should the nurse take? A. Ensure that the electric outlet has two prolongs for the IV pump B. Check the clouds of the IV pump for fraying C. Grasp the IV pump cord when unplugging it from the electrical outlet D. Remove the safety inspection sticker before plugging in the IV pump ------CORRECT ANSWER-------------B. Check the clouds of the IV pump for fraying A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 ml/hr. Which of the following interventions should the nurse anticipate? A. Clamp the (Unable to read) B. Administer fluid bolus. C. Obtain a urine specimen for culture and sensitivity D. Initiate continuous bladder irrigation. ------CORRECT ANSWER-------------C. Obtain a urine specimen for culture and sensitivity A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine? A. Heart rate 58/min A nurse is reviewing the laboratory report of a client who has a prescription for digoxin. For which of the following laboratory results should the nurse withhold the medication and notify the provider? Digoxin 0.8 ng/ml Sodium (Was out of range) BUN 15 Potassium 3.1 mEq/L. ------CORRECT ANSWER-------------Potassium 3.1 mEq/L. A nurse is caring for a client who wears glasses. Which of the following actions should the nurse take? A. Store the glasses in a labeled case. B. Clean the glasses with hot water. C. Clean the glasses with a paper towel. D. Store the glasses on the bedside table. ------CORRECT ANSWER-------------A. Store the glasses in a labeled case. A school nurse is teaching a parent about absent seizures. Which of the following information should the nurse include? A. "This type of seizure can be mistaken for daydreaming." B. "This type of seizure lasts 30 to 60 seconds." C. "The child usually has an aura prior to onset." D. "This type of seizure has a gradual onset." ------CORRECT ANSWER-------------A. "This type of seizure can be mistaken for daydreaming." A nurse is planning care for a client who has cancer and is about to receive low dose brachytherapy via a vaginal implant applicator. Which of the following interventions should the nurse include in the plan of care? A. Removal of vaginal packing B. Insertion of an indwelling urinary catheter C. Ambulation four times daily D. Maintenance of NPO status until therapy is complete ------CORRECT ANSWER------- ------B. Insertion of an indwelling urinary catheter A nurse is caring for a client who has deep vein thrombosis and is receiving heparin therapy. Which of the following tests should the nurse use to monitor and regulate the dosage of the medications? A. aPTT. B. Pyro (Unsure if that's the writing) C. Platelet count. D. INR. ------CORRECT ANSWER-------------A. aPTT. A charge nurse is preparing to lead negotiations among nursing staff due to conflict about overtime requirements. Which of the following strategies should the nurse use to promote effective negotiation? A. Identify solutions prior to negotiation B. Focus on how the conflict occurred C. Attempts to understand both sides of the issue D. Personalize the conflict ------CORRECT ANSWER-------------C. Attempts to understand both sides of the issue A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. Which of the following instructions should the nurse include? A. Use the client's children to provide interpretation. B. (Answer was the nurse was going to do the interpretation) C. Offer client's translation services for a nominal fee. D. Evaluate the clients' understanding at regular intervals. ------CORRECT ANSWER---- ---------B. (Answer was the nurse was going to do the interpretation) A nurse is caring for a client who experienced a traumatic brain injury 72 hr. ago. Which of the following findings should the nurse identify as an indication of intercranial pressure? A. Tachycardia. B. Narrowed pulse pressure. C. Hypotension. D. Increasingly severe headache. ------CORRECT ANSWER-------------D. Increasingly severe headache.