VATI Comprehensive Predictor NCLEX Questions with 100% correct answers /2024-2025, Exams of Nursing

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VATI Comprehensive Predictor NCLEX Questions

with 100% correct answers /2024-

1. Low-residue diet: Dairy products & eggs, such as custard and yogurt (Rat) A low-residue diet consists of foods that are low in fiber and are easy to digest such as eggs, custard, yogurt and ripe bananas - NOTE Legumes such as lentils and black beans are high in fiber and are not considered low in residue.
2. A RN is caring for a patient who weighs 80 kg and is 5 ft 3 in tall. Calculate the BMI and determine if the patients BMI indicates a healthy weight, underweight, overweight, or obese.: Use the formula (wt. in lbs)/(ht in in^2) multiply by 703 to get the BMI. BMI is 31 (obese) (Rat) A BMI greater than 30 indicates obesity. A BMI of 25-29.9 indicates overweight. A BMI of 18.5- 24.9 is a normal/healthy BMI. A BMI <18.5 indicates underweight.
3. A RN admits a female patient who weighs 246 lbs with a height of 5 ft 4 in. Calculate the BMI of the female patient.: Use the formula (lbs)/(in^2) multiply by 703 BMI 42 indicates the patient is obese 4. A RN is reviewing discharge instructions regarding car seat safety to the parent of a newborn. Which of the following instructions will the nurse include in the discharge teaching (SATA) A. Position the infant rear-facing in the backseat. B. Be sure the car seat is at a 90 degree angle C. Be sure the care seat is at a 45 degree angle D. Position the car seat behind the passenger or drivers seat E. Position the care seat in the middle of the back seat F. Keep infants in rear-facing car seats until age 6 months G. Keep infants in rear-facing car seat until 2 yr old or until the child reaches the maximum ht and wt for the seat.: (A, C, E, G) A. Position the infant rear-facing in the backseat - (RAT) the car seat should never be in the front seat of a car due to the increased risk for injury from the air bags during a MVA. C. Be sure the care seat is at a 45 degree angle - (RAT) the car seat should be at a 45 degree angle. E. Position the care seat in the middle of the back seat - (RAT) the car seat should be in the middle

away from air bags and side impact. G. Keep infants in rear-facing car seat until 2 yr - (RAT) keep the child in the rear-fac-

ing car seat until the child reaches 2yo or until the child reaches the maximum ht and wt for the seat.

5. A RN is caring for a patient who fell at a nursing home. The patient is oriented x 3 (person, place & time) and can follow directions. Which of the following actions should the RN take to decrease the risk of another fall? (SATA) A. Place a belt restraint on the patient when they are sitting on the bedside commode B. Keep the bed in its lowest position with all side rails up C. Make sure that the patient's call light is within reach D. Provide the patient with nonskid footwear E. Complete a fall-risk assessment: (C,D,E) C. Make sure that the patient's call light is within reach D.Provide the patient with nonskid footwear E. Complete a fall-risk assessment Note- You do not put all the side rails up in the bed because this is considered a restraint. 6. A RN is caring for a patient who has a Hx of falls. Which of the following actions is the RNs priority? A. Complete a fall-risk assessment B. Educate the patient and family about fall risks C. Eliminate safety hazards from the patients environment D. Make sure the patient uses assistive aids in their possession: A. Complete a fall-risk assessment (Rat) this is a priority nursing question therefore the question should direct you to

the nursing process. The first action the nurse should take using the nursing process is to assess or collect data from the patient.

7. A RN discovers a small paper fire in a trash in a patients bathroom. The patient has been taken to safety and the alarm has been activated. Which of the following actions should the RN take? A. Open the windows in the patients room to allow smoke to escape B. Obtain a class C fire extinguisher to extinguish the fire C. Remove all electrical equipment from the patient room D. Place wet towels along the base of the door to the patients room: D. Place wet towels along the base of the door to the patients room - (RAT) to contain the fire and smoke in the room. Note - do not obtain a class C fire extinguisher but instead obtain a class A fire extinguisher which is used for ordinary combustibles such as cloth and paper.

8. A nurse manager is completing an in-service on a group of new nurses in the transition to practice program. The nurse manager asks one nurse student to define the acronym "RACE". Please indicate what each letter in the acronym means.: R - Rescue and protect the patients who are at or near the fire. Patients who can walk are able to do so on command to a safe location. A - Activate the alarm C - Contain/confine the fire by closing doors and windows, by placing a wet towel under the door in the patients room, and by turning off all oxygen sources and any electrical devices. Ventilate patient's who are on life support by using a bag-valve mask E - Extinguish the fire with a general/appropriate fire extinguisher (Class A) for your normal combustables 9. A RN discovers that she administered an antihypertensive medication to a patient in error. Identify the appropriate sequence of steps that the RN should take using the following actions. A. Call the MD B. Check the VS C. Notify the risk manager

D. Complete an incident report E. Instruct the patient to remain in bed until further notice: (A, B, C, D, E) A. Call the MD B. Check the VS C. Notify the risk manager D.Complete an incident report E. Instruct the patient to remain in bed until further notice Note - If the question was a priority question, what would the RN do first? First, I would check the VS.

10. A RN is discussing disaster planning with the board members of a hospital. Which of the following actions should the RN take? A. Incident commander B. Medical command physician C. Triage officer D. Media liaison: Medical command physician - (RAT) oversee's the use of re- sources (equipment and personnel) NOTE - the incident commander manages the incident and key leaders within the facility NOTE - Expect the triage officer to prioritize the treatment of patients coming in for treatment NOTE - Expect the media liaison to communicate with members of the media and press on behalf of the facility

11. A RN prepares the ER to admit patients who were exposed to inhalation anthrax during a bioterrorism attack. Which antibiotic is used to treat patients who have been exposed to inhalation anthrax?: Ciprofloxacin (Cipro) will treat and prevent the spread of anthrax (RAT) Ciprofloxacin and doxycycline IV/PO is used following exposure. Treatment in- cludes one or two additional antibiotic (vancomycin, penicillin and anthrax antitoxin) 12. A RN at a mental health clinic is caring for four patients. The RN should recognize the following patients is using dissociation as a defense mecha-

nism?: A patient who was abused as a child describes the abuse as if it happened to someone else

13. What are the signs and symptoms of hypoglycemia? Use the mnemonic He IS TIRED!: He - Headache I - Irritability S - Sweating T - Tachycardia I - Irritability R - Restlessness E - Excessive Hunger D - Dizziness
14. The RN is working with a new MD. The RN is preparing the patient for the administration of an epidural. The RN consult the MD for the verification of which medication ordered?: Heparin (RAT) Heparin can cause spinal hematoma

• the risk for hematoma at the puncture site for spinal or epidural medication administration is increased while taking heparin. NOTE - Factors that further increase risk include taking other anticoagulants or antiplatelet medications, Hx of spinal problems or surgery or use of an indwelling epidural catheter. NURSING CONSIDERATIONS - In patients who have spinal or epidural anesthesia: Assess insertion site for indications of hematoma formation (redness, swelling). Monitor sensation and movement of lower extremities. Notify MD of abnormal findings.

15. A nurse is caring for a patient who is receiving chemotherapy. The patient's absolute neutrophil count (ANC) is less than 1,000/mm3. What precautions should the nurse institute?: Neutropenic Precautions (RAT) The risk of serious infection increases as the ANC falls. An ANC less than 1,000/mm^ indicates a weak immune system and the need to initiate neutropenic precautions. 16. A charge RN is teaching a group of unit nurses about the policy for patients who have a history of MRSA. Which of the following information should the nurse include? A. A patient who has a history of MRSA will need antibiotics B. A patient who has a Hx of MRSA can develop immunity to the infection

C. A patient who has a Hx of MRSA requires a protective environment D. A patient who has a Hx of MRSA can still transmit the infection: D. A patient who has a Hx of MRSA can still transmit the infection

17. Identify the diseases the nurse should report to the CDC: Staphylococcus aureus (VISA/VRSA) Syphilis Smallpox Viral hemorrhagic fever (Ebola/Yellow Fever) Vancomycin- intermediate and vancomycin-resistant Typhoid fever/ Toxic shock syndrome (TSS) /Tetanus Pertussis (whooping cough) Mumps Legionnaires disease (a severe form of pneumonia) Anthrax Botulism NOTE: Don't report HPV to the CDC 18. A RN is determining the attack rate following an E.coli outbreak at a restaurant. If 84 people ate contaminated lettuce, and 13 people developed an E.coli infection, what should the nurse conclude as the attack rate? Use the formula: (# of exposed people who develop infection)/(# exposed people) = attack rate multiply by 100 to get the percentage 15 19. A RN is reviewing data on the rates of varicella zoster (Chicken pox) for a country. If there were 416 cases of varicella in one year among a population of 32,000 people, what should the nurse record as the incidence rate per 1,000 people? Use the formula: (#cases)/(#population) x 1, 13
18. List three actions the RN should take when caring for a patient exposed to anthrax.: Apply Oxygen Establish an IV Administer Cipro/Doxycycline ABT.
19. A charge nurse is teaching the patient how to identify the difference be- tween antisocial personality d/o and narcissistic personality disorder. Please use the mnemonic CALLOUS MAN to describe antisocial personality d/o.: C - conduct d/o before age 15yr, charming

A - arrests L

• lies L - lacks a superego & empathy for others O - obligations not honored U - unstable, can't plan ahead S - sense of entitlement, seductive, not safe M - manipulative, $ problems & irresponsible A - aggressive and assaultive N - not calm, actions are impulsive

22. List three (3) risk factors for intimate partner violence.: - One of the highest risks for intimate partner violence is when the partner threatens to leave.

• Pregnancy that is unexpected or unwanted
• Witnessing violence in the home or being a victim of growing up
• Female

23. A nurse is caring for a client with acute mania. Provide an example of one structured activity the nurse will incorporate into the client's daily schedule.: - Safety is the number one priority in patients in acute mania. Assessments are continuous to ensure the patient will not harm self or others.

• Provide a quiet environment - seclusion may be required
• One structured activity for a patient with acute mania is walking or exercising.
• ECT can be used during manic episodes/rapid cycling, when the patient is a danger to self or others.

24. The nurse is preparing a client for a surgical procedure with regional anesthesia and is reviewing the medication list. The client reports that he took his warfarin last night. What action should the nurse take?: - The nurse should notify the MD

• Collect labs to read the INR; an INR of 1.1 or below is normal; for a person taking warfarin an INR range of 2.0 - 3.0 is an effective therapeutic range.

25. A RN in the labor and delivery unit is caring for a patient who is undergoing external fetal monitoring. The RN observes that the FHR begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which os the following actions should the RN take first?: Place the patient in lateral position (RAT) This is a late deceleration and is associated with fetal hypoxemia due to

insufficient placental perfusion, placing the patient in the lateral position is the 1st action the RN should take (NOTE) Late decelerations are associated are also with insufficient placental perfu- sion. Placing the patient in the lateral position is the 1st action the nurse should take

• also administer 8-10 L of O2 but position change is 1st. Hint: Think VEAL CHOP "L" Late decelerations "P" Placental insufficiency

26. A RN is caring for a newborn with a small gestational age (SGA). Which of the following findings is associated with this condition?: Wide skull sutures (RAT) Small "newbies" aka premies have wide skull sutures due to inadequate bone growth. Head circumferences smaller than the normal newborn and there is reduced brain capacity. (NOTE) SGA newborns have sunken abd not abd that protrude; they also have loose dry skin and a thin yellowish umbilical cord that looks dull and dry.
27. A RN is preparing to measure the fundal height of a patient who is at 22 WOG. At which location should the RN expect to palpate the fundus?: Slightly above the belly button (RAT) Anything between 20-22 WOG is approximately at the level/slightly above the belly button & anything <20 WOG is below the belly button. Monitor for supine hypotension (NOTE) 3 cm above the belly button means the fundal height indicates the gestation to be > WOG.
28. A RN is admitting a patient who has a diagnosis of preterm labor. The nurse anticipates a order by the MD for which of the following medications (SATA): Indomethacin - relaxes & suppresses the uterus and is commonly used in preterm labor Mag Sulfate - used to prevent seizures & is a tocolytic (meaning that is stops/halts preterm labor contractions) "the baby needs a little more time to bake". (NOTE) Oxytocin is incorrect - we don't want to cause contractions we want to stop them.

29. Hydrops fetalis: caused by chronic intrauterine anemia ie. Rh isoimmunization, caused by blood incompatability. Ex. Rh neg mom with a Ph pos baby. The Rh pos blood enters mom - note: this is what hydrops fetalis is
30. A patient reports awaking from sleep by contractions that are occurring every five minutes and lasting 30 - 40 seconds. Which of the following ques- tions should the nurse ask to assess for true labor vs false labor?: "Have you noticed any bloody show or fluid coming from your vagina" (RAT) True labor has nothing to do with the start of contractions 31. A patient in the early postpartum period is talkative and enjoys recounting the details of her labor and birth. The RN recognizes that the behaviors must likely indicate which the following?: The taking in phase of the maternal postpartum adjustment (RAT) Positive mom-infant bonding is incorrect - the bonding describes behaviors r/t maternal adaptation to mothering the newborn, not specifically newborn-mother interaction which would be indicative of positive bonding.
31. A RN is caring for a neonate who exhibits abstinence syndrome (NAS) and demonstrates clinical manifestations of the condition. Which assessment finding is associated with this condition?: Hypothermia (RAT) NAS is the result of the neonate withdrawing from drugs as the neonate is detached from the maternal supply. (NOTE) baby's with NAS will not present with diminished/decreased DTR's but in- creased DTR's instead, increased muscle tone, increased hypersensitivity to sound and external stimuli
32. Thirty minutes after admissions to the nursing an infant appeared jittery and exhibits a weak high pitched cry. Which of the following would be the nurses priority action?: Performs a heel stick (RAT) the infant may be experiencing hypoglycemia and a heel stick will allow the nurse to test the BS to assess glucose. (NOT) A drug screen is not the priority action
33. A RN is performing a fundal assessment in the patient's second post- partum day. Which of the following should the RN expect if the patient is experiencing normal involution?: The fundus will present one cm below the belly button

35. The patient asks the nurses to explain the difference between true and false labor. Which of the following is an example of true labor?: In true labor the uterus will dilate and efface (NOTE) It is not true that the presenting part is engaged; most of the time when the patient is in true labor the presenting part is engaged - and is not a solid indication that this is true labor.
36. A RN is caring for a patient who has been prescribed mag sulfate as tocolytic therapy. Several hours after the infusion was started, contractions ceased. Which of the following is the best analysis os this data?: The drug is having a therapeutic effect (RAT) It is incorrect to assess DTR's; while DTR's should be assessed with a patient receiving mag sulfate this is not required based on this data.
37. A patient who is 32 weeks pregnant presents to the ER with bright red vaginal bleeding for the last 3 hours. The patient reports feeling fetal move- ment since the bleeding started. Which of the following is the nurses priority action?: Assess maternal VS (NOTE) Do not assess the fetal heart tones; since the mother is feeling the baby move this is not necessary.
38. A patient with gestational DM gave birth to a 9 LB neonate 12 hr ago. The neonate is presenting with a high pitched cry and jitteriness. Which of the following is the nurses priority intervention?: Offer the neonate breast milk or formula (NOTE) it is incorrect to provide the neonate with O2 via oxyhood; the neonate does not present with respiratory distress or a low muffled cry.
39. A patient diagnosed with pregnancy induced HTN has been receiving a Mag Sulfate infusion for three days. Serum drug levels have been b/t 8-10 mg/dL. Which of the following findings should the RN expect to assess in the infant after delivery?: Lethargy & respiratory depression (RAT) Tachycardia and respiratory distress is incorrect
40. A RN is caring for a newborn diagnosed with neonatal infection. Which of the following risk factors is most important to the care os this patient?: Ma- ternal Hx of cytomegalovirus (NOTE) the answer is not a decrease in the number of functional alveoli; a decrease

in the number of functional alveoli within the lung may lead to respiratory distress of apnea but is not necessarily a predisposing factor for a neonatal infection

41. A RN is assessing a patient in the immediate postpartum period. The fundus is boggy and deviated to the left of the belly button. Which of the following is the most appropriate intervention?: Assist the patient to void (NOTE) to assess the lochia is incorrect, while it will be appropriate to assess lochia a displaced uterus indicates a full bladder. 42. A RN at a family-planning clinic is developing a program about teen sex- uality. Which of the following is a developmental task of teen according to Erikson's theory of psychosocial development? A. Adjusting to dramatic changes to body image B. Developing hypothetical reasoning skills C. Establishing the capacity for an intimate love relationship D. Learning to make good choices and avoid risk-taking behaviors: A. Adjusting to dramatic changes to body image (RAT) the major developmental task in teens (12-18 YO) is identify vs. role confusion. Teens are preoccupied with their changing bodies and how their bodies appear to others. (NOTE) Intimacy vs isolation stage occurs in early adulthood & safety is not a major developmental task for teens. However, risk-taking behaviors are the primary reason for unintentional injury, which is the most common cause of death in teens. 43. A RN is preparing to meet with a patient who has borderline personality d/o. Which of the following actions should the nurse plan to take during the working phase of the therapeutic relationship? A. Introduce the concept of patient confidentiality B. Establish goals with the patient C. Define the roles of the nurse and patient D. Facilitate a change in the patients behavior: D. Facilitate a change in the

patients behavior (RAT) confidentiality, goals and roles are established during the orientation phase of the therapeutic relationship

44. A RN is caring for an older adult patient who has difficulty following a CVA. Which of the following actions should the RN take when assisting the RN at mealtime? A. Encourage the RN to drink fluids before swallowing food B. Offer the RN tart or sour foods first C. Tilt the RN's head backward when swallowing D. Turn on the TV: B. Offer the RN tart or sour foods first (RAT) A patient who has impaired swallowing should consume tart and sour foods at the beginning of the meal to stimulate saliva production, which aids chewing and swallowing. 45. A public health nurse is assisting community leaders to develop a disaster response plan in the event of an outbreak of a serious communicable dis- ease. When teaching the community leaders about infectious disease, the RN should explain that a vector is of which of the following? A. A mode of transmission for the disease B. A microorganism that causes the infection C. An environment where the pathogen can survive D. A patient who is susceptible to the infection: A. A mode of transmission for the disease (RAT) Think of a vector as a car the vector is there the bacteria/microorganism resides to get to the host. 46. A RN is caring for a patient who has osteoporosis and a new order for calcium supplements. Which of the following foods should the RN recommend to promote calcium absorption?

A. Fortified milk B. Ripe bananas C. Steamed broccoli D. Green leafy vegetables: A. Fortified milk (RAT) Provides nearly 2.5 mcg of Vit D, which promotes calcium absorption from the GI tract. Adults up to age 70 require 600 IU of Vit D/per day and 800 IU thereafter. Therefore, fortified milk is a good source of Vit D.

47. A RN is preparing a patient for cardiac catheterization Which of the follow- ing pieces of information should the RN give the patient before the procedure? (SATA) A. "You'll have to lie flat for several hours after the procedure." B. " You'll receive medication to relax you before the procedure." C. " You'll feel a cool sensation after the injection of the dye." D. " You'll have to keep your leg straight after the procedure." E. "You'll have to limit the amount of fluid you drink for the first 24 hr.": A. "You'll have to lie flat for several hours after the procedure." D. " You'll have to keep your leg straight after the procedure." E. "You'll have to limit the amount of fluid you drink for the first 24 hr." 48. A RN is preparing an in-service presentation about the management of a MI. Death following a MI is often a result of which of the following complica- tions? A. Cardiogenic shock B. Dysrhythmias C. HF

D. Pulmonary edema: B. Dysrhythmias (RAT) F-fib is one of the most common causes of death following a MI. Therefore the nurse should monitor EKG's carefully for these alterations in the heart rhythm and report and treat them STAT. (NOTE) Cardiogenic shock, HF and pulmonary edema are complications of MI, but is not the most common cause of death following MI. Other complications include emboli and pericarditis.

49. A RN is planning care for a patient who has deep partial-thickness and full-thickness thermal burns over 40% of his total body surface and is in the acute phase f burn injury. Which of the following interventions should the RN include in the plan? A. Initiate ROM exercises B. Use clean technique to provide wound care C. Place the patient on a low-protein diet D. Maintain the patient on bed rest: A. Initiate ROM exercises (RAT) to maintain mobility and to prevent contracture 50. A charge nurse is observing a newly licensed RN irrigate a patient's ear, which is impacted with cerumen. Which of the following actions requires the charge RN to intervene? A. Visualizing the eardrum before irrigating B. Instilling 50 mL of fluid with each irrigation C. Using firm, continuous pressure while irrigating D. Warming the irrigation fluid to at least 37C (98F): B. Instilling 50 mL of fluid with each irrigation (RAT) When irrigating a patient's ear the RN should use no more than 5 - 10 mL of irrigating fluid at a time to decrease the chance of stimulating the vestibular nerve of the inner ear, which would result in N&V or dizziness.

51. A RN is preparing an in-service program about the stages of AKI. Which of the following pieces of information should the RN include about prerenal azotemia? A. Prerenal azotemia begins prior to the onset of s/s B. Interference with renal perfusion causes prerenal azotemia C. Prerenal azotemia is irreversible, even in the early stages D. Infections and tumors cause prerenal azotemia: B. Interference with renal perfusion causes prerenal azotemia (RAT) Prerenal azotemia refers to elevations in BUN and Creat resulting from prob- lems in the systemic circulation that decrease flow to the kidneys. The decreased renal flow stimulates salt and water retention to restore volume and pressure - Prerenal axotemia results from interference with renal perfusion, such as from HF or hypovolemic shock. 52. A RN at a LTC facility notes a patient with dementia is having problems with orientation. Which of the following actions should the RN take to improve the patients level of orientation? A. Encourage the patient to make choices about meals and activities B. Use written signs to label specific rooms C. Post a large calendar on the bulletin board D. Place an electronic wander alert bracelet on the patient's wrist: C. Post a large calendar on the bulletin board (RAT) Posting a large calendar in a central location will assist this patient with orientation 53. A RN is assessing a patient who is receiving a transfusion of PRBC's. Which of the following findings should the RN identify as an indication of an acute intravascular hemolytic reaction? A. Severe hypertension

B. Low body temperature C. Sudden oliguria D. Decreased respirations: C. Sudden oliguria (RAT) The RN should identify sudden oliguria as an indication of an acute intravas- cular hemolytic reaction. This type of transfusion reaction causes acute kidney injury resulting in sudden oliguria and hemoglobinuria. This reaction results from the patients antibodies reacting to the transfused RBC's.

54. A RN is conducting a health assessment for a 24-MO toddler at the local health department. The RN should expect which of the following findings? (SATA) A. 8 deciduous teeth B. Ability to build a tower of 6 blocks C. Vocabulary of 10-20 words D. Slightly bowed or curved leg appearance E. Head circumference greater than chest circumference: B. Ability to build a tower of 6 blocks D. Slightly bowed or curved leg appearance (NOTE) A 24 MO should have 16 teeth and a vocabulary of 300 words and to be able to speak in 2-3 word phrases. 55. A RN in the ER is assisting with the care of a 4 YO who ingested toilet bowel cleaner. The child has hemoptysis, is crying, and states, "It burns." Which of the following actions should the RN perform? (SATA) A. Identify how much cleaner was in the bottle B. Administer activated charcoal C. Perform immediate gastric lavage

D. Insert an IV for morphine administration E. Apply a pulse oximeter: A. Identify how much cleaner was in the bottle D. Insert an IV for morphine administration E. Apply a pulse oximeter (RAT) Activated charcoal is contraindicated for the treatment of poisoning with a corrosive agent because these substances can burn tissue, which the charcoal could then infiltrate - gastric lavage is contraindicated for the treatment of poisoning with a corrosive agent because this could re-expose the upper GI system to the corrosive substance, which can result in further injury.

56. A RN is preparing a patient who is scheduled to have an arthroscopy the following day. Which of the following statements indicates that the patient understands the pre-procedure teaching? A. "I have to keep my leg straight throughout the whole procedure." B. "The doctor will be able to see if I have signs of RA C. "I should expect to stay overnight until I can walk around." D. "Ill have a scar that will be about an inch long.": B. "The doctor will be able to see if I have signs of RA (RAT) An arthroscopy helps with diagnosing musculoskeletal d/o such as RA, osteoarthritis, and internal joint injuries 57. A RN is caring for a patient who has a TBI and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the RN anticipate when drawing a blood sample? A. The patient rigidly extends his arms B. The patient internally flexes his wrists C. The patient curls into a fetal position D. The patient internally rotates his legs: A. The patient rigidly extends his arms

(RAT) a patient who exhibits decorticate posturing internally flexes the wrists and arms and extends and plantar-flexes the legs

58. A RN is performing a physical assessment of a patient. Which of the fol- lowing actions should the nurse take to assess the patients tissue perfusion? A. Perform a Romberg test B. Check nails for Beau's lines C. Palpate for respiratory excursion D. Perform a blanch test: D. Perform a blanch test (RAT) The blanch test is used to check capillary refill, which is an indicator of peripheral circulation and tissue perfusion (NOTE) Beau's lines are depressions in the nail from temporary disturbance of nail growth. Beau's lines are caused by systemic illness or injury and are not indicators of tissue perfision 59. A RN is performing a straight urinary catheterization for a female patient who has urinary retention. Which of the following actions indicates the RN is maintaining sterile technique? A. Applying sterile gloves to open the catheter package B. Wiping the labia minora in an anteriorposterios direction C. Spreading the labia with the dominate hand D. Using a cotton ball to wipe right and left labia majora: B. Wiping the labia minora in an anteriorposterios direction (NOTE) The RN should use the nondominate hand to spread the labia and provide the optimal view of the urethral meatus 60. A RN is caring for a patient who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the RN expect? A. Frequent BS with gas

B. Absent BS with distention C. Hyperactive BS with diarrhea D. Normal BS with increased peristalsis: B. Absent BS with distention (RAT) Paralytic ileus is an immobile bowel. In this disorder, BS are absent and the abdomen is distended.

61. A RN is providing teaching about nutritious diets to a group of adult women. Which of the following statements should the RN include? A. "Include at least 3 g of Na in your daily diet." B. "Limit wine consumption to 239 mL daily." C. "Include 2.5 cups of veggies in your daily diet." D. "Limit water intake to 1.5 L each day.": C. "Include 2.5 cups of veggies in your daily diet." (RAT) Instruct women to consume 2.5 cups of veggies and 2 cups of fruit in the diet. (NOTE) The recommended amount of ETOH for women is a drink per day, which is equivalent to 350 mL (12 oz) of beer, 148 mL (5 oz) of wine, or 44 mL (1.5 oz) of hard ETOH that is over 80 proof.

62. What do you know about a Pulse ?: A pulse of 4+ is bounding and does not disappear with moderate pressure. Pulse strength ranges from absent (0) to bounding (4+). 63. A RN is assessing a patient who is experiencing stress and anxiety regard- ing a recent diagnosis. Which of the following findings should the RN expect ? A. Increased BP B. Decreased BS level C. Decreased O2 use

D. Increased GI motility: A. Increased BP (RAT) Stress and anxiety can cause the BP to increase and the HR to increase as a result of the SNS stimulation

64. A RN is preparing to insert an NG tube for a patient who has a bowel obstruction. Which of the following actions should the RN take first? A. Give the patient a glass of water B. Assist the patient into a sitting position C. Explain the procedure to the patient D. Measure the length of tubing to be inserted: C. Explain the procedure to the patient 65. A RN is assessing a patient who is undergoing a physical examination. Following the inspection, which of the following techniques should the RN use next when assessing the RN's abdomen? A. Auscultation B. Light palpation C. Percussion D. Deep palpation: A. Auscultation 66. A RN is teaching a patient how to self-administer insulin. Which of the following actions should the RN take to evaluate the patient's understanding of the process within the psychomotor domain of learning? A. Ask the patient if he wants to self-administer B. Have the patient list the steps of the procedure C. Have the patient demonstrates the procedure D. Ask the patient if he understands the purpose of insulin: C. Have the patient demonstrates the procedure

(RAT) The patient demonstrating the procedure provides the RN the ability to evaluate the patient's understanding within the psychomotor domain of learning

67. A RN is planning care for a patient who has schizophrenia and reports auditory hallucinations. Which of the following interventions should the RN include in the plan? A. Promote the use of music to compete with the client's auditory hallucina- tions. B. Inform the client that the auditory hallucinations are not real. C. Avoid asking the client if they are experiencing auditory hallucinations. D. Instruct the client on the use of voice recognition regarding the auditory hallucinations.: A. Promote the use of music to compete with the client's auditory hallucinations. (RAT) Competing reality-based stimulation such as the use of music or TV during auditory hallucinations can assist in limiting the effect the hallucinations have on the patient's stress level. 68. A RN is documenting admission assessment findings for a patient who has MDD. The RN should identify which of the following findings as clinical manifestations? (SATA) A. Feelings of hopelessness B. Pressured speech C. Grandiosity D. Anhedonia E. Flat facial expression: A. Feelings of hopelessness D. Anhedonia E. Flat facial expression (RAT) Anhedonia is the inability to experience pleasure as a clinical manifestation of MDD.

69. A RN is planning care for a patient who is experiencing acute mania. Which of the following interventions should the RN include in the POC to promote sleep? A. Have the client participate in a morning aerobics group. B. Encourage frequent rest periods throughout the day. C. Provide a distraction such as television at night. D. Offer the client hot chocolate at bedtime.: B. Encourage frequent rest periods throughout the day. (RAT) A client who is experiencing acute mania is at risk for sleep disturbances and might go for extended periods of time without sleep. Encouraging periods of rest throughout the day can limit the risk of exhaustion (NOTE) The nurse should direct the client to areas with minimal activity to decrease stimulation. so (A) is incorrect. 70. A RN is caring for a group of patients. Which of the following findings should the RN report? A. A client who is taking clozapine and has a WBC count of 7,500/mm3 B. A client who is taking lamotrigine and has developed a rash C. A client who is taking valproate and has a platelet count of 150,000/mm3 D. A client who is taking lithium and has a lithium level of 1.2 mEq/L: B. A client who is taking lamotrigine and has developed a rash (RAT) Lamotrigine is an anticonvulsant medication that is used as a mood stabilizer. The nurse should identify that a rash is a potentially life-threatening adverse effect of the medication and report this finding immediately (NOTE) Lithium is a medication used for mood stabilization for clients who have bipolar disorder. The nurse should identify that the lithium toxicity can result in serious complications, including death. However, a lithium level of 1.2 mEq/L is within the therapeutic range. (Normal Ref. Range for lithium is 0.6 - 1.2 mEq/L

71. A RN is admitting a patient who has anorexia nervosa and is at 60% of ideal body weight. Which os the following interventions should the RN include in the POC? A. Encourage the client to drink 125 mL of fluid each hour while awake. B. Allow the client to eat independently in their room. C. Weigh the client twice weekly. D. Measure the client's vital signs once each day.: A. Encourage the client to drink 125 mL of fluid each hour while awake. (RAT) The nurse should encourage the client to drink 125 mL of fluid each waking hour to maintain hydration. (NOTE) Initially, the nurse should measure the client's vital signs three times each day until the client's weight increases and cardiovascular status improves - so measuring the patients VS once each day is incorrect. 72. During morning rounds a RN finds a patient who has schizophrenia trem- bling and tearful in their bed. The patient reports that a bomb was placed in their room by a family member during visiting hours. Which of the following actions should the RN take? A. Ask the client to identify the bomb in the room. B. Initiate disaster protocols per facility policies and procedures. C. Assess the client for evidence of a perceptual disturbance. D. Convince the client that there is no bomb in their room.: C. Assess the client for evidence of a perceptual disturbance. (RAT) The nurse should assess the situation to determine if the client is hallucinating or misperceiving external stimuli, also known as experiencing illusions. (NOTE) Trying to convince the client that there is not a bomb in their room negates the client's experience - so convincing the patient that there is no bomb in their room is the incorrect action to take

73. A RN in a clinic is assessing a patient whose partner died 4 months ago. Which of the following statements indicates that the patient is at risk for complicated grief? A. "I wish I had been nicer and more generous with my wife before she died." B. "I told my wife to go to the doctor, but she wouldn't listen to me." C. "I think about my wife all the time when I go on outings with my family." D. "I feel so empty without my wife that it's hard to get up every morning.": D. "I feel so empty without my wife that it's hard to get up every morning." (RAT) The nurse should identify that when a client has difficulty carrying on normal activities following a loss, this is an indication that there is a risk for complicated grief. (NOTE) The nurse should identify that the client is expressing guilt, which is an expected finding of grief - so - the patient stating "I wish I had been nicer and more generous with my wife before she died" is an incorrect statement 74. A RN in an ER is admitting a patient who reports experiencing a HA and heart palpitations after having a glass of wine 1 hr ago. The patient has a Hx of depression and a BP of 210/105 mmHg and a temp of 39.9 C (103.8 F). Which of the following actions should the nurse take first? A. Administer phentolamine 5 mg IV to the client. B. Apply a hypothermic blanket to the client. C. Determine the client's prescribed medication regimen. D. Initiate IV access for the client.: C. Determine the client's prescribed medication regimen. (RAT) The first action the nurse should take when using the nursing process is to assess the client. By determining the client's prescribed medications, the nurse can determine the cause of the hypertension, such as the client taking an MAOI to treat depression. These medications can precipitate a hypertensive crisis if consumed with tyramine-containing foods, including wine.