ATI COMPREHENSIVE C | Complete Solution
1. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The
nurse obtained a ... [Show More] verbal prescription for restraints. Which of the following should the actions the
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
2. A nursing planning care for a school-age child who is 4 hr postoperative following
perforated appendicitis. Which of the following actions should the nurse include in the plan of
a. Offer small amounts of clear liquids 6 hr following surgery (assess for gag reflex first)
b. Give cromolyn nebulizer solution every 6 hr (for asthma)
c. Apply a warm compress to the operative site every 4 hr
d. Administer analgesics on a scheduled basis for the first 24 hr
3. A nurse is receiving change-of-shift report for a group of clients. Which of the following
clients should the nurse plan to assess first?
a. A client who has sinus arrhythmia and is receiving cardiac monitoring
b. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%
c. A client who has epidural analgesia and weakness in the lower extremities
d. A client who has a hip fracture and a new onset of tachypnea
4. A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the
following actions should the nurse tak e?
a. Shave hairy areas of skin prior to application (apply to hairless, clean & dry areas to promote
absorption; avoid oily or broken skin)
b. Wear gloves to apply the patch to the client’s skin
c. Apply the patch within 1 hr of removing it from the protective pouch (apply immediately)
d. Remove the previous patch and place it in a tissue (fold patch in half with sticky sides
5. A nurse has just received change-of-shift report for four clients. Which of the following
clients should the nurse assess first?
a. A client who was just given a glass of orange juice for a low blood glucose level
b. A client who is schedule for a procedure in 1 hr (can wait)
c. A client who has 100 mL fluid remaining in his IV bag (can wait)
d. A client who received a pain medication 30 min ago for postoperative pain
6. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of
the following places the client at risk for aspiration?
a. A history of gastroesophageal reflux disease
b. Receiving a high osmolarity formula
c. Sitting in a high-Fowler’s position during the feeding
d. A residual of 65 mL 1hr postprandial
7. A nurse is reviewing the laboratory results for a client who has Cushing’s disease. The
nurse should expect the client to have an increase in which of the following laboratory values?
a. Serum glucose level- increased
b. Serum calcium level-decreased
c. Lymphocyte count- decreased immune system.
d. Serum potassium level- decreased
. 8. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium
sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displaces
toxicity. Which of the following actions should the nurse take?
a. Position the client supine
b. Prepare an IV bolus of dextrose 5% in water
c. Administer methylergonovine IM
d. Administer calcium gluconate IV
Calcium gluconate is given for magnesium sulfate toxicity. Always have an injectable form of
calcium gluconate available when administering magnesium sulfate by IV.
9. 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. Experiencing delusions
b. Male gender
c. Previous violent behavior
d. A history of being in prison
Risk factors also include: past history of aggression, poor impulse control, and violence.
Comorbidity that leads to acts of violence (psychotic delusions, command hallucinations, violent
angry reactions with cognitive disorders).
Individual Assessment for Violence
10. A nurse is preparing to perform a sterile dressing change. Which of the following actions
should the nurse take when setting up the sterile field?
a. Place the cap from the solution sterile side up on clean surface
b. Open the outermost flap of the sterile kit toward the body→ flap AWAY from the body's
c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field → 2.5 cm
(1-inch) border around any sterile drape or wrap that is considered contaminated.
d. Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW waist level; should
be ABOVE waist level
11. 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. Eat a light snack before bedtime
b. Stay in bed at least 1 hr if unable to fall asleep
c. Take a 1 hr nap during the day
d. Perform exercises prior to bedtime
12. A home health nurse is preparing for an initial visit with an older adult client who lives
alone. Which of the following actions should the nurse take first?
a. Educate the client about current medical diagnosis
b. Refer the client to a meal delivery program
c. Identify environmental hazards in the home
d. Arrange for client transportation to follow-up appointments
Rationale Priority: Assess first.
13. A nurse is assessing the remote memory of an older adult client who has mild dementia.
Which of the following questions should the nurse ask the client?
a. “Can you tell me who visited you today?”
b. “What high school did you graduate from
c. “Can you list your current medications?”
d. “What did you have for breakfast yesterday?”
14. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of
the following goals should the nurse include in the teaching
a. HbA1c level greater than 8%- 6.5 - 8 is the target reference. >
b. Blood glucose level greater than 200 mg/dL at bedtime
c. Blood glucose level less than 60 mg/dL before breakfast- < 70 = HYPOGLYCEMIC
d. HbA1c level less than 7%
15. A nurse is caring for a client who is receiving phenytoin for management of grand mal
seizures and has a new prescription for isoniazid and rifampin . Which of the following should
the nurse conclude if the client develops ataxia and incoordination?
a. The client is experiencing an adverse reaction to rifampin
b. The client’s seizure disorder is no longer under control
c . The client is showing evidence of phenytoin toxicity
d. The client is having adverse effects due to combination antimicrobial therapy
16. A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the
following manifestations requires immediate action by the nurse?
a. Increase in frequency of swallowing → may indicate bleeding
b. Moderate sanguineous drainage on the drip pad
c. Bruising to the face→ side effect
d. Absent gag reflex→ possibly due to anesthesia given. (1 hour postoperative)
Rationale “Requires immediate action” choose the worst possibility that could lead to. ABC
17. A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki
disease. Which of the following interventions should the nurse include in the plan of care?
a. Give scheduled doses of acetaminophen every 6 hr
b. Monitor the child’s cardiac status
c. Administer antibiotics via intermittent IV bolus for 24 hr
d. Provide stimulation with children of the same age in the playroom
18. A nurse is planning an educational program for high school students about cigarette
smoking. Which of the following potential consequences of smoking is most likely to discourage
adolescents from using tobacco?
a. Use of tobacco might lead to alcohol and drug abuse
b. Smoking in adolescence increases the risk of developing lung cancer later in life
c. Use of tobacco decreases the level of athletic ability
d. Smoking in adolescence increases the risk of lifelong addiction
19. A nurse is assessing a client who is prescribed spironolactone. Which of the following
laboratory values should the nurse monitor for this client?
a. Total bilirubin
b. Urine ketones
c. Serum potassium- diuretic that retains potassium= hyperkalemic risk
d. Platelet count
Rationale ATI PDF p: 146 Pharm Complications: hyperkalemia
20. A nurse has agreed to serve as an interpreter for an older adult client who is assigned to
another nurse. Which of the following statements by the nurse indicates an understanding of this
a. “I will let the client know that I am available as the interpreter.”
b. “I will receive a small fee for interpreting for this client.”
c. “I am glad I’m available today, but when I’m not, you can use a family member.”
d. “I will let the client know that an interpreter is unavailable during the night shift.”
21. A nurse is performing assessments on newborns in the nursery. Which of the following
findings should the nurse report to the provider?
a. A two day old newborn who has a respiratory rate of 70 --> 30 - 60 is normal
b. A 16 hour old new newborn who has yet to pass meconium- you got 24 hours to pass
c, A 2 day old newborn who has a small amount of blood tinged vaginal discharge
d. A 16 hr old newborn whose blood glucose is 45 mg/dl- 40 - 60 is normal
22. A nurse on an acute unit has received change of shift report for 4 clients which of the
following clients should the nurse assess first? Pain pallor pulselessness paresthesia
a. A client who is 1 hr postoperative and has hypoactive bowel sounds
b. A client who has fractured left tibia and pallor in the affected extremity
c. A client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses
d. A client who has a elevated AST level following administration of azithromycin
23. A nurse is providing discharge instructions to a client who has a new prescription for
haloperidol which of the following adverse effects should the nurse instruct the client to report to
a. Weight gain
b. Dry mouth→ anticholinergic effects
c. Sedation → s/s neuroleptic malignant syndrome??>> life threatening
d. Shuffling gait →A/E EPS: is an indication of parkinsonism and should be reported to t
24. 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? P . 177 ch 26
a. Clean the base of the cord with hydrogen peroxide daily- only with tub and sponge baths
b. The cord stump will fall off in 5 days- about 10 - 14 days
c. Contact the provider if the cord stump turns black
d. Keep the cord stump dry until it falls off
Rationale: cord usually falls out within 7 to 10 days. Clean with soap and water. Cord is
expected to turn black and dry.
25. A nurse is teaching dietary guidelines to a client who has celiac disease which of the
following food choices is appropriate for the client?
a. White flour tortillas
b. Potato pancakes
c. Wheat crackers
d. Canned barley soup
26. A nurse is working in acute care mental health facility is assessing a client who has
schizophrenia. Which of the following findings should the nurse expect?
a. All or nothing thinking
b. Euphoric mood
c. Disorganized speech
d. Hypochondriasis ( anxiety disorder)
27. A nurse is caring for a client who is immobile which of the following interventions is
appropriate to prevent contracture?
a. Align a trochanter wedge between the clients legs
b. Place a towel roll under the clients neck
c. Apply an orthotic to the clients foot
d. Position a pillow under the client's knees
28. A public health nurse working in a rural area is developing a program to improve health for
the local population. Which of the following actions should the nurse plan to take?
a. Provide anticipatory guidance classes to parents through public schools
b. Have a nurse from the outside the community provide health lectures at the county
c. Encourage rural residents to focus health spending on tertiary health interventions
d. Launch a media campaign to increase awareness about industrial pollution
29. A nurse in the 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 → ESI Level 1
b. 10cm (4 in) laceration → ESI Level 4
c. Fractured tibia → ESI Level 2; if pelvis, femur, or hip and other extremity dislocation
then level 1.
d. 95% full thickness body burn →
30. A nurse is preparing a change of shift report for an adult female client who is postoperative.
Which of the following client information should the nurse include in the report?
a. Hgb 12.8 g/dl - 12- 16
b. Potassium 4.2 meq/l 3.5 - 5.0 meq
c. RBC 4.4 million/mm3
d. Platelets 100,000/mm3 - 150,000 - 300,000 risk for bleeding
31. A nurse is admitting a client who has anorexia nervosa. Which of the following is an
a. Iron 90 mcg/dl
b. Prealbumin 10 mcg/dl (normal: 16-40)
c. Serum creatinine 0.8 mg/dl
d. Calcium 9.5 mg/dl
32. 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 assignments should the nurse delegate to the LPN?
a. A client who is postoperative following a bowel resection with an NGT set to
b. A client who has fractured a femur yesterday and is expecting SOB
c. A client who sustained a concussion and has unequal pupils
d. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs
33. A nurse is caring for a client who is at 41 week of gestation and is receiving oxytocin for
labor induction. The nurse notes early deceleration on the fetal heart rate monitor . Which of the
following nursing actions should the nurse take ? p . 88 ch 13 maternity
a. Continue the monitor the fetal heart rate- - Not a problem- absent or late are a
problem however CONFIRMED
b. Stop the oxytocin infusion
c. Perform a vaginal examination
d. Initiate an amnioinfusion
34. A nurse is conducting an initial assessment of a client and noticed a discrepancy between the
clients current IV infusion and the information received during the shift report. Which of the
following actions should the nurse take?
a. Complete an incident report and place it in the client's medical record.
b. Compare the current infusion with the prescription in the client's medication
c. Contact the charge nurse to see if the prescription was changed.
d. Submit a written warning for the nurse involved in the incident.
35. 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. WBC count 2,900 /mm3 - AGRANULOCYTOSIS - 4,800- 15,000 is normal range
b. FAsting blood glucose 100 mg/dl
c. Hgb 14 g/Dl
d. Heart rate 58/min
ATI PHARM 116 Complications
36. A nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis C.
The client asks the nurse if she will be able to breastfeed. Which of the following responses by
the nurse is appropriate?
a. You may breastfeed unless your nipples are cracked or bleeding.
b. You must use a breast pump to provide breast milk.
c. You must use nipple shield when breastfeeding.
d. You may breastfeed after your baby develops his antibiotics.
37. A nurse is caring for a client who has returned to the medical-surgical unit following a
transurethral resection of the prostate. Which of the following should the nurse identify as
priority nursing assessment after reviewing the clients information? Exhibit.
a. Level of consciousness. (priority)- decreased LOC can mean less o2 going to the
b. Skin turgor
c. Deep-tendon reflexes
d. Bowel sounds
38. A nurse is caring for a client who has hyperthermia .Which of the following actions for the
nurse to take ?
a. Submerge the adolescent feet in ice water
b. Cover the adolescent with a thermal blanket → if hypothermia.
c. Administer oral acetaminophen
d. Initiate seizure precautions
39. A nurse manager is updating protocols for belt restraints. Which of the following guidelines
should the nurse include.
a. Document the client's conditions every 15 minutes
b. Attach the restraints to the beds side rails
c. Request a PRN restraints prescription for clients who are aggressive
d. Remove the client restraints every 4 hours
40. A nurse in emergency department is caring for a client who has full thickness burn of the
thorax and upper torso. After securing the client's airway, which of the following is the nurse's
P. 482 ch 75 CONFIRMED
a. Providing pain management
b. Offering emotional support
c. Preventing infection
d. Initiating IV fluid resuscitation - they are at risk for hypovolemic shock d/t 3rd
41. A nurse is caring for a client who has cancer and is being transferred to hospice care. The
client’s daughter tells the nurse, “I’m not sure what to say to my mom if she asks me about
dying.” which of the following responses by the nurse is appropriate? (SATA)
A. Hospice will take good care of your mom, so I wouldn’t worry about that.
B. Let's talk about your mom’s cancer and how things will progress from here.
C. Tell me how you are feeling about your mom dying.
D. Tell her not to worry. She still has plenty of time left.
E. You sound like you have questions about your mom dying. Let’s talk about it.
Rationale: Therapeutic communication
42. A nurse is reviewing the medical records of four clients. The nurse should identify that which
of the following client findings follow up care?
a. A client who is taking bumetanide and has potassium level of 3.6 mEq/L (normal)
b. A client who is scheduled for colonoscopy and taking sodium phosphate
c. A client who received a Mantoux test 48 hours ago and has induration
d. A client who is taking warfarin and has INR of 1.8 (normal if taking warfarin)
43. A community health nurse receives a referral for a family home visit. Which of the following
tasks should the nurse perform first?
a. Clarify the source of the referral
b. Implement the nursing process
c. Schedule a time for the home visit
d. Contact the family by phone
44. A nurse is caring for a client who will undergo a procedure. The client states he does not
want the provider to discuss the results with his partner. Which of the following is an appropriate
response for the nurse to make?
a. You have the right to decide who receives information -
b. Your partner can be a great source of support for you at this time
c. Is there a reason you don’t want your partner to know about your procedure?
d. The provider will be tactful when talking to your partner
45. A nurse is discussing a weight loss with a client who is concerned about losing 6.8 kg (15lb)
from an original weight of 9o.7 (200 lb). The nurse should identify the weight of the following
46. A nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate.
Which of the following interventions should the nurse implement?
a. Perform fundal massage ( massage if fundus is boggy)
b. Pour water from a squeeze bottle over the client’s perineal area.
c. Insert an indwelling urinary catheter.
d. Apply cold therapy to the client’s perineal area.( warm)
47. A nurse is providing discharge teaching to a client who has cancer and a prescription for a
fentanyl 25 mcg /hr transdermal patch. Which of the following instructions should the nurse
include in the teaching?
a. Avoid hot tub while wearing the patch
b. Apply patch to your forearm
c. Avoid high-fiber foods while taking this medication
d. Remove the patch for 8 hours every day to reduce the risk for tolerance.
48. A nurse working on a surgical unit is developing a care plan for a client who has paraplegia.
The client has an area of non-blanchable erythema over his ischium. Which of the following
interventions should the nurse include in the care plan?
a. Teach the client to shift his weight every 15 min while sitting (cannot do this because
he is paraplegic)
b. Place the client upright on a donut-shaped cushion
c. Assess pressure points every 24 hr.- must assess
d. Turn and reposition the client every 3 hrs. while in bed. - must be q 2 hours in bed, 1
hour in chair.
49. A nurse is working with a client who has an anxiety disorder and is in the orientation phase
of the therapeutic relationship. Which of the following statements should the nurse make during
a. We should discuss resources to implement in your daily life
b. Let me show you simple relaxation exercises to manage stress.
c. Let’s talk about how you can change your response to stress
d. We should establish our roles in the initial session.
50. A nurse is providing discharge teaching to a client who has a new prescription for
phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods
while taking this medication?
b. Whole grain bread
c. Pepperoni pizza
d. Smoked salmon ?????
51. A nurse enters a client’s room and sees a small fire in the client’s bathroom. Identify the
sequence of steps the nurse should take. (Move the steps into the box on the right, placing them
in the selected order of performance. Use all steps)
a. Transport the client to another area of the nursing unit (1)
b. Activate the facility’s fire alarm system (2)
c. Close all nearby windows and doors (3)
d. Use the unit’s fire extinguisher to attempt to put out the fire (4)
52. A nurse is caring for a client who is experiencing mild anxiety . Which of the following
findings should the nurse expect?
a. Heightened perceptual field
b. Rapid speech -severe
c. Feelings of dread
d. Purposeless activity
53. A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is
not feeling well. Which of the following findings should indicate to the nurse that the client is
hypoglycemic ? (Select all that apply.)
b. Polydipsia = hyperglycemia
c. Acetone Breath odor = DKA
e. Inability to concentrate
54. A nurse is caring for an infant who has coarctation of the aorta. Which of the following
should the nurse identify as an expected finding?
a. Upper extremity hypotension
b. Increased intracranial pressure
c. Frequent nosebleeds
d. Weak femoral pulses
55. A community health nurse is planning primary prevention activities to reduce the occurrence
of abuse. Which of the following strategies should the nurse include in the plan?
a. Instruct healthcare professionals to identify abusive situations (screening=secondary
b. Locate financial support to open a shelter for abuse survivors (3rd)
c. Teach parenting skills to families at risk for abuse
d. Connect abuse survivors with legal counsel (3rd)
56 . A nurse and an assistive personnel (AP) are caring for a group of clients. Which of the
following tasks is appropriate for the nurse to delegate to the AP?
a. Documenting the report of pain for a client who is postoperative
b. Administering oral fluids to a client who has dysphagiac.
Applying a condom catheter for a client who has a spinal cord injury
d. Reviewing active range-of-motion exercise with a client who had a stroke
57. A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the
following statements by the client indicates an understanding of the teaching?
a. “I will take sucralfate with meals three times per day”
b. “I will avoid food and beverages that contain caffeine”
c. “I will decrease my daily protein intake to 15 grams per day”
d. “I will use ibuprofen as needed to control abdominal pain”
58. A nurse is caring for a client who reports xerostomia following radiation therapy to the
mandible. Which of the following is an appropriate action by the nurse?
a. Offer the client saltine crackers between meals
b. Suggest rinsing his mouth with an alcohol-based mouthwash
c. Provide humidification of the room air
d. Instruct the client on the use of esophageal speech
59. A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an
a. Assess effectiveness of antiemetic medicationb.
Perform chest compressions during cardiac resuscitation -
c. Perform a dressing change for a new amputeed.
Apply a transdermal nicotine patch-
*60. A nurse is caring for a client who states he recently purchased lavender oil to use when he
gets the flu. The nurse should recognize which of the following findings as a potential
contraindication for using lavender?
a. The client takes vitamin C daily
b. The client has a history of alcohol use disorder
c. The client has a history of asthma
d. The client takes furosemide twice daily
61. A nurse is caring for a client who has major depressive disorder and a new prescription for
amitriptyline . The nurse should monitor for which of the following adverse effects?
a. Increased salivation- dry it will cause - anticholinergic effects
b. Weight loss
c. Urinary retention -
d. Hypertension- orthostatic hypotension it will cause instead
62. A nurse is conducting a health promotion class about the use of oral contraceptives. Which of
the following disorders is a contraindication for oral contraceptive use?
d. Fibrocystic breast condition
63. A nurse is preparing to witness a client’s signature on a consent form for a colon resection.
The nurse should recognize that which of the following information should be provided to the
client by the provider before signing the form? (SATA)
a. Explain the procedure
b. Expected outcome of the procedure
c. Potential complications
d. Possible alternative treatments
e. Cost of the procedure
64. A nurse is providing teaching to a client who will undergo a magnetic resonance imaging
(MRI) scan. Which of the following statements is appropriate to include in the teaching?
a. “You should not have this procedure if you are allergic to iodine.”
b. “You should not have this procedure if you have a tattoo.”
c. “The nurse will ask you to wear protective eyewear during this procedure.”
d. “The nurse will ask you to remove any transdermal patches prior to the procedure.”
65 . A nurse in a provider’s office is reviewing a female client’s medical record during a routine
visit. The nurse should recommend increasing dietary intake of which of the following vitamins?
--only tab shown is Tab 3:
H&P: postmenopausal, hx DVT and iron deficiency anemia, works indoors, consumes 1-2
alcoholic beverages per week
a. Vitamin D
b. Vitamin K
c. Vitamin A
d. Vitamin B12
66. A nurse is caring for a child who has sickle cell anemia and experiencing vaso-constrictive
crisis. Which of the following actions should the nurse include in the plan of care?
a. Initiate IV fluid replacementb.
Start a 24-hr urine collection- not the priority
c. Give aspirin to reduce pain- acetaminophen or ibuprofen. Asa might lead to reye's disease
d. Encourage ambulation- we want to promote rest to decrease 02 consumption
67. A nurse is teaching a parent about safety securing her 3-month-old infant in a car seat. Which
of the following images indicates that the parent understands the teaching? B
a. B .
C and D not shown
68 . A nurse is caring for an adult client who has chronic anemia and is scheduled to receive a
transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take? P.
249 med surg pdf
a. Check the client’s vital signs from the previous shift prior to the initiation of the transfusionassess
prior to infusion then be with them for first 15 - 30 minutes.
b. Set the IV infusion pump to administer the blood over 6 hr
c. Flush the blood administration tubing with 0.9% sodium chloride prior to the
Administer the blood via a 21-gauge IV needle
69. A nurse is caring for a client who is dissatisfied with the care from the provider and decides
to leave the facility against medical advice. After notifying the provider, which of the following
actions is appropriate for the nurse to take?
a. Summon a security guard
b. Explain the risks of leaving
c. Complete an incident report
d. Notify a social worker
70. A nurse is making an initial postpartum home visit. Which of the following client statements
should the nurse identify as a manifestation of increased risk for child abuse?
a. “I try to respond to the baby quickly .”
b. “ I think the baby should be sleeping through the night by now.
c. “I have several friends who come by to help out with the baby.”
d. “I want to meet other parents to see if they are going through the same thing.”
71. A nurse is caring for an infant who has gastroenteritis. Which of the following assessments
should the nurse report to the provider?
a. Temperature 38 C(100.4 F) and pulse rate 124/min p
b. Decreased appetite and irritability
c. Pale and 24-hour fluid deficit of 30 mL
d. Sunken fontanels and dry mucous membranes
72. A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal
bleeding, The nurse does not speak the same language as the client . The client partner and a 10
year old child are accompanying her. Which of the following actions should the nurse take to
gather the clients information?
Request a female translator interpreter through the facility
a. Ask a student nurse who speaks the same language to translate
b. Have the child translate
c. Allow the clients partner to translate
73. A nurse is caring for a client who has pernicious anemia, Which of the following laboratory
values should the nurse evaluate effectiveness of the treatment ?
A. Folate level
B. INR level
C. Vitamin b12 level
D. Creatinine level
74. A nurse is assigning tasks to assistive personnel(AP). Which of the following tasks should
the nurse assign to the AP?
a. Suction a new tracheostomy
b. Remove an NG tube
c. Perform post mortem care
d. Change the dressing on an implanted central venous access device
75. A nurse is caring for a client who is postpartum and reports difficulty voiding. Which of the
following findings should indicate to the nurse that the client’s ability to eliminate urine from the
bladder is restored?
a. Two voids of 150 mL each over the past 2 hours= 2 x 30 = 60 mls
b. Fundus 2 fingerbreadths above the umbilicus( needs to be below or at the umbilicus)
c. Uterine atony( fundus not firm which means possible hemorrhage)
d. Fundus firm and to the right of the abdominal midline( fundus not midline, bladder may
cause shifting if patient not voiding properly)
76. A nurse is caring for a client who has acute glomerulonephritis .Which of the following
should the nurse expect ?
a. Polyuria- oliguria
b. Hypotension- hypertension
c. Hematuria - urinalysis will show red blood cells and protein, also reddish brown col
d. Weight loss - weight gain
77. A nurse is providing teaching to a client about the adverse effects of sertraline . Which of the
following effects should the nurse include ? p. 50 ch 7 pharm pdf SSRI for social anxiety ,
A. Excessive sweating
B. Increased urinary frequency
C. Dry cough
D. Metallic taste in mouth
78. A nurse is providing teaching to the parents of a newborn about genetic screening. Which of
the following statements should the nurse include in the teaching?
a. your baby will be given 2 ounces of water to drink prior to the test
b. this test will be repeated when your baby is 2 months old
c. a nurse will draw blood from your baby’s inner elbow
d. this test should be performed after you baby is 24 hours old
79. a nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of
the following actions should the nurse take?
a. perform the procedure prior to meals : AVOID Before or AFTER meals
b. perform the procedure twice a day
c. administer a bronchodilator after the procedured.
hold hand flat to perform percussions on the child-
80. a nurse is preparing an inservice for a group of nurses about malpractice issues in nursing.
Which of the following examples should the nurse include in the teaching?
a. placing a yellow bracelet on a client who is at risk for falls→ correct approach; yellow
bracelet indicates fall risk
b. administering potassium via IV bolus
c. documenting communication with a provider in the progress notes of the client’s medical
d. leaving a nasogastric tube clamped after administering oral medication →
81. A nurse in a clinic is assessing a client who reports frequent headaches. Identify the area the
nurse should palpate to check the client’s maxillary sinus for tenderness.
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Palpate the maxillary sinuses by pressing upward at the
skin crevices that run from the sides of the nose to the
corner of the mouth.
82. A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following
actions should the nurse instruct the client to take prior to initiating postural drainage?
a. Take pancrelipase
b. Complete oral hygiene
c. Eat a meal
d. Use an albuterol inhaler
83. A nurse is caring for a client following a cardiac catheterization through the left groin. Which
of the following actions should the nurse take? P . 164 ch 27 medsurge
a. Monitor the dorsalis pedis pulse every 15 minutes → circulation
b. Maintain strict bedrest for first 12 hr- only for prescribed time, older adults usally are up
to 4 hours.
c. Keep the client NPO for 24 hr- doesn’t say anything about restrictions AFTER the
procedure , and npo b4 the procedure is uP to 8 hours.
d. Place the client in Fowler’s position- supine they must be
84. A nurse is caring for a client who has depression and is experiencing loss of appetite. Which
of the following actions should the nurse take?
a. Offer high-calorie, high protein snacks to the client
b. Recommend the family provide the client privacy during meals
c. Weigh the client once each day
d. Encourage the client to eat foods selected by the dietitian
85. A nurse is caring for a client who requests to ambulate in the hallway with his own clothing.
The nurse is demonstrating which of the following ethical principles when respecting the client's
decision to wear his own clothing ?
a. Non maleficence
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Autonomy: The ability of the client to make personal
decisions, even when those decisions might not be in
the client’s own best interest
86. A nurse in an emergency department is caring for a toddler who has burns following a house
fire. Which of the following actions should the nurse take first ?
A. Check the mouth for smooth and smoky breath - airway obstruction via foreign
B. Calculate the fluid replacement based on vital signs and urinary output
C. Determine the location and depth of burns
D. Administer antibiotics to prevent sepsis.
87. A nurse is assessing a client who had heart failure is taking furosemide. Which of the
following findings should the nurse monitor ?
a. Hyponatremia - loop diuretic (Lasix) - wherever water goes sodium and potassium will
88 . a nurse Is caring for a client who weighs 75 kg. the client has a prescription from a dietician
to decrease calorie intake by 500 cal/day for 25 weeks produce a weight loss of 1 pound per
week. What is the expected goal weight for the client in pounds at the end of the 25 weeks?
(round the answer to the nearest whole number. Use leading zero if it applies. No trailing Zero)
_____140??(not sure)_______ pounds
1 lb per week x 25 week= 25 lbs
75 x 2.2= 165 lbs
165 lbs-25 lbs=140 lbs or 63.6 kg (64 kg)
89. a nurse is providing discharge teaching about circumcision care to a parent of a newborn.
Which of the following statements by the parent indicates an understanding of the teaching?
a. I will change my baby’s diaper at least every 4 hours
b. I will apply an ice pack to my baby’s penis twice daily to decrease swelling
c. I will wash the penis with soap and warm water until the circumcision has healed
d. I will apply topical lidocaine following each diaper change
Teach the parents to keep the area clean.
90 . a home health nurse is caring for an adult client who reports, “I keep coughing when I try to
swallow my food, but not at other times.” Which of the following actions should the nurse take?
a. encourage the client to increase fluid intake
b. initiate a consultation with a speech→ language pathologist; swallow eval
c. instruct the client that this is due to increased salivary flow that occurs with aging
d. recommend an antitussive 30 minutes prior to each meal
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Refer to speech language therapist for dysarthria
91 . A nurse is caring for a client who is insulin dependent and is undergoing tests to determine
if his blood glucose is being adequately controlled. The nurse should identify that which of the
following laboratory values is the best indicator of adequate blood glucose control?
A. Postprandial blood glucose 190 mg/dl
B. Fasting blood glucose 60 mg/dl
C. HbA1c 6.5%
D. Hct 42%
92. A nurse is planning to administer Atenolol to a client. Which of the following should the
nurse assess prior to administering the medication?
B. Blood pressure
C. Respiratory rate
93. A nurse is orienting a newly licensed nurse while caring for clients who are in labor. Which
of the following pain management strategies by the newly licensed nurse requires
A. Encouraging the client to use jet therapy on her lower back for 1 hr
B. Placing a transcutaneous electrical nerve stimulation (TENS) unit on a client’s abdomen
C. Using effleurage on a client’s lower abdomen
D. Instructing a client’s partner how to apply counterpressure to the client’s sacral spine for 30
94 . A nurse has identified tasks to delegate to a group of assistive personnel (AP) after receiving
change-of-shift report. Identify the sequence of step s the nurse should follow when delegating
tasks to the APs.
A. Review the skill level of and qualifications of each AP 1
B. Communicate appropriate tasks to the APs with specific expectations 2
C. Monitor progress of task completion with each AP 3
D. Evaluate the APs’ performance of each task 4
95. A nurse is teaching a prenatal class about infection prevention at a community center. Which
of the following statements by a client indicates an understanding of the teaching?
A. “I should take antibiotics when I have a virus.”
B. “I should wash my hands for 10 seconds with hot water after working in the garden.”
C. “I can clean my cat’s litter box during my pregnancy.”
D. “ I can visit my nephew who has chickenpox 5 days after the sores have crusted .”
96. A nurse I caring for a school-age child who is 2 hr postoperative following a cardiac
catheterization. The nurse observes blood on the child’s dressing. Which of the following
actions should the nurse take?
A. Apply intermittent pressure 2.5 cm (1 in) below the percutaneous skin site.
B. Apply continuous pressure 2.5 cm (1 in) below the percutaneous skin site.
C. Apply continuous pressure 2.5 cm (1 in) above the percutaneous skin site.
D. Apply intermittent pressure 2.5 cm (1 in) above the percutaneous skin site.
97. A nurse is reviewing the medical record of a client who has a prescription for intermittent
heat therapy for a foot injury. Which if the following findings should the nurse identify as a
contraindication for heat therapy?
B. Abdominal aortic aneurysm
D . Peripheral neuropathy
98. A nurse is providing teaching to a client who is to undergo a cardiac catheterization. Which
of the following findings is expected during the procedure?
A. Sensation of skin warmth
C. Increased salivation
D. Numbness and tingling of the extremities
99. 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 clarification?
A. Lorazepam .5 mg PO one tablet daily
B. Hydrochlorothiazide 12.5 mg PO BID
C. Triamcinolone acetonide 100 mcg/inhalation two puffs TID
D. Zolpidem 10 mg PO one tablet at bedtime
100 . A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to
report to the provider. Which of the following findings should the nurse include in the
A . Swelling of the face
B. Urinary frequency
C. Faintness upon rising
D. Bleeding gums
101. A nurse is providing care for a client who has esophageal cancer and has received radiation
therapy. Which of the following finding should the nurse identify as the priority?
A. Excoriation of the skin on the neck and chest
B. Dysphagi a
C. Client reports a pain level of 6 on scale from 0-10
102. A nurse is assessing a client who is 2 hrs postpartum for uterine atony . Which of the
following action should the nurse take?
A. Monitor the client’s urinary output
B. Check the client VS
C. Evaluate the client's pain level
D. Palpate the client’s fundus
103. A school nurse is teaching a parent about absence seizures. Which of the following
information should the nurse include?
A. “This type of seizure can be mistaken for daydreaming”
B. “The child usually has an aura prior to onset”
C. This type of seizure last 30-60 sec”
D. “This type of seizure has a gradual onset”
104. A nurse in a surgical suite is planning care for a client who requires surgery and has a latex
sensitivity. Which of the following is appropriate for this client?
A. Disinfect and powder any latex products before use
B. Tape stockinet over monitoring device and cords
C. Schedule the client as the last surgery of the day
D. Remove poopsocks from the IV
105 . A nurse is reviewing the medical record of a client. The nurse should identify that the client
is at risk for which of the following complication.
A Dumping syndrome
D Thyroid storm
106. A nurse is caring for a client who has lung cancer and has a sealed radiation implant. Which
of the following action should nurse take? (SATA)
A. Place the client in a semi-private room
B. Wear a lead apron when providing care
C. Limit visitors to 30 mins
D. Instruct visitors who are pregnant to remain 3 ft from the client
E. Close the door to the client's room
107. A CN (charge nurse) is providing teaching for group of newly licensed nurse about grieving
process. Which of the following information should the CN include in the teaching?
A. Client can expect to have feeling of hopelessness
B. Client might feel guilt over some aspect of their loss
C. Client will experience anhedonia
D. Client will experience low self-esteem
108. A client who is pregnant voice her concern that her 3y/o son will feel left out one the newborn
arrives. Which of the following statements by the nurse is appropriate?
A. Offer your son a gift when the baby receives one
B. Move your son to a toddler bed when the baby arrives
C. Tell your son to kiss the baby
D. Teach your son to change the baby diapers - not the answer
109. A nurse is obtaining a nutritional health hx on a client who reports problems with constipation.
Which of the following should the nurse identify as a cause of constipation?
A. Following high-fiber diet
B. Currently taking probiotics-
C. New prescription for an iron supplement
D. Intolerance to lactose
110. A nurse is assessing a newborn who has patent ductus arteriosus . Which of the following findings
should the nurse except?
A. Increase PaO2
C. Board-like abdomen
D. Bounding pulse
111. 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. Measure the client’s urine output every hour. - monitor for toxicity.
b. Restrict the client’s total fluid intake to 250ml/hr.
c. Monitor the FHR via Doppler every 30 min
d. Give the client protamine if sign of magnesium sulfate toxicity occur.
112. 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 conditions
in the child’s medical history should the nurse identify as a contraindication to the procedure?
b. Primary glaucoma
113. A nurse is caring for a client who has COPD and is 5kg (11lb) below her ideal body weight.
The client experiences shortness of breath when eating. Which of the following actions should
the nurse take?
a. Administer a bronchodilator following meals.
b. Request non gas forming foods from the dietary department
c. Limit the client’s food consumption between meals.
d. Arrange for a low protein diet. HIGH PROTEIN.
114. 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 infectious disease that
should be reported to the state health department?
b. Herpes simplex virus
c. Human papillomavirus
115 . A nurse is reviewing the laboratory findings of a client who is receiving IV infusion of
insulin. The client’s lab findings reveal a potassium level of 5.5 mEq/L, BUN of 15 mg/dL, and
a creatinine level of 1 mg/dL. Which of the following interventions is appropriate for the nurse to
a. Place a cardiac monitor on the client
b. Stop the IV infusion of insulin
c. Administer oral potassium to the client- potassium is already high
d. Initiate a 24 hr urine collection
116. A nurse is providing discharge teaching to a client who is postoperative following the
surgical repair of a detached retina. Which of the following statements by the client indicates an
understanding of the teaching?
a. I can go jogging after 2 weeks. -Avoid vigorous activities.
b. I can lift objects that are less than 10 seconds. -avoid lifting more than 5pounds.
c. I can resume activities, such as sewing.
d. I should bend at the waist when putting on my shoes. -Avoid bending at the waist level.
117. A nurse is planning to administer vancomycin IV to a client. Which of the following actions
should the nurse take to reduce the risk of an adverse reaction to the vancomycin?
a. Give the dose over 60 min
b. Administer the medication undiluted
c. Obtain trough level 30 min after the medication infusion
d. Inject 1% lidocaine prior to each dose
118. 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
a. Take magnesium hydroxide for indigestion -not for pts with CKD or dialysis.
b. Eat 1g/kg of protein per day
c. Drink at least 3L of fluid daily -too much fluid
d. Consume foods high in potassium -low potassium diet
119. A nurse is delegating tasks to an assistive personnel group of clients. Which of the
following statements should the nurse make?
a. Take the client in room 106 to radiologyb.
Take the vital signs of the clients on the side of the unit
c. T ell me the standing weight of the client in room 102 before breakfast
d. The client in room 109 has spilled his water pitcher
Rationale : right direction/communication. Leadership.
120. A nurse is caring for a client who has heart failure and is receiving a continuous IV infusion
of low dose dopamine. Which of the following findings is the highest priority?
a. Erythema 5 cm (2in) above the IV site
b. Blood pressure 92/68 mm Hg -
c. Urine output 35mL/hr
d. Pedal pulse of +1 bilaterally
121. A nurse is providing teaching about the use of crutches using a three-point gait to a client
who has tibia fracture. Which of the following actions by the client indicates an understanding of
A. Positioning both hands on the grips with his elbows slightly flexed
B. Supporting his body weight while leaning on the axillary crutch pads (Support body
weight using both Crutches when shifting weight)
C. Stepping with his affected leg first when going up stairs (Unaffected First)
D. Moving both crutches with the stronger leg forward
122. A nurse is assessing a 24-month-old toddler during a well-child visit. Which of the
following developmental tasks should the toddler be able to perform?
A. Hop on one foot
B. Kick a ball forward
C. Climb Stairs with alternate feet
D. Ride a tricycle
123. A case manager is meeting with a client who asks about using alternative therapies to
manage her rheumatoid arthritis. Which of the following statements should the nurse make?
A. Im sure you can find alternative remedies through an online support group
B. If there are therapies available to you, your provider will tell you about them
C. Feel free to try whatever therapies that fit within your personal belief system
D. We can review some information to help you select a safe alternative practitioner .
● Facilitating conti
● Improving efficiency of care and utilization of resources 124. A nurse is assessing a client
following a ischemic stroke. Which of the following findings is the priority for the nurse to
report to the provider?
A. The client reports a metallic taste in his mouth
B. A client reports a decreased appetite
C. The client coughs after swallowing
D. The client has poor fitting dentures
125. A nurse is caring for a client who has end-stage liver disease and is undergoing a
paracentesis. Which of the following actions should the nurse take to evaluate effectiveness of
A. C ompare the client's current weight with preprocedure weight.
B. Check the client's serum albumin levels
C. Examine for leakage at thes site of the procedure
D. Confirm that the client is able to urinate
126. A nurse is developing a plan of care for a newborn whose mother tested positive for heroin
during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the
following actions should the nurse include in the plan?
A. Swaddle the newborn with this leg extended.
B. Maintain eye contact with the newborn during feedings.
C. Minimize noise in the newborn environment
D. Administer naloxone to the newborn
● Reduce environmental stimuli (decrease lights, lower noise level).
127 . A newly licensed nurse is reviewing the role of a nurse in disaster planning. Which of the
following is an activity a nurse should engage in to assist in disaster preparedness?
A. Participate in community drills and mock events .
B. Vaccinate susceptible children and adults against smallpox
C. Assess types, levels and scopes of disasters.
D. Make quarantine preparations for those exposed to anthrax
Rationale: Assess First
128. A nurse is completing an admission assess for a client who has narcissistic personality
disorder. Which of the findings should the nurse expect?
A. Ritualistic behavior (OCD)
B. Exhibits separation anxiety (Dependent)
C . Preoccupied with aging
D. Suspicious of others. (Paranoid)
129. 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. Withdraw the client's TV privileges if he does not attend group therapy
B. Place the client in seclusion when exhibits signs of anxiety
C. Encourage the client to take frequent rest perio ds.
D. Encourage the client to spend time in the day room
130. A nurse is obtaining a client’s medical history before initiating 1000 ml of 0.9% NaCl with
20 mEq/L KCl IV to correct hypokalemia. Which of the following findings is a contraindication
to the client receiving this IV solution?
A. Severe renal impairment. (Stage IV Kidney Disease)
B. Chronic alcohol use disorder
C. Multiple sclerosis
D. Advanced cardiac disease.
131. A nurse is auscultating heart sounds of an adult client experiencing dyspnea. The nurse
hears a soft, turbulent sound between beats at the left midclavicular line in the fifth intercostal
space. Which of the following is an appropriate documentation of the findings?
a. Fourth heart sound at the aortic area
b. Murmur at the mitral area
c. Third heart sound at the tricuspid area
d. Pericardial friction rub at the pulmonic area
132 . A nurse is teaching a client who has a newly documented latex allergy. Which of the
following statements by the clients indicates an understanding of the teaching?
a. I will remove dairy products from my diet
b. I will remove peanuts from my diet
c. I will remove bananas from my diet
d. I will remove gluten from my diet
● People allergic to latex also allergic to avocado, banana, chestnut, kiwi, passion fruit,
plum, strawberry, tomato
133 . A nurse is obtaining a medical history from a client who has a new diagnosis of type 2
diabetes mellitus. The nurse should report which of the following conditions is a contraindication
for the use of metformin?
a. Seizure disorder
b. Polycystic ovary syndrome
c. Renal insufficiency
d. Gluten intolerance
134 . A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis.
The nurse should monitor the client for which of the following complications?
a. Contractions -
d. Epigastric pain -google
135. A nurse on a surgical pediatric care unit receives report prior to providing care for a group
of clients. Which of the following clients should the nurse assess first?
a. A 15 year old who is 6 hr postop following a herniorrhaphy and reports pain at the IV site
b. 3 month old who is 1 day postop following cleft lip repair and has a pulse of 120
c. 12 year old who is 2 days postop following an appendectomy and is refusing to ambulate
d. 8 year old client who is 12 hr postop following a tonsillectomy and is experiencing
frequent swallowing - bleeding
136. A nurse is teaching a client how to perform kegel exercises. Which of the following client
statements indicates understanding of the teaching?
a. I will alternately contract and relax my gluteal muscles
b. I will perform the exercises once each day before bed
c. I will try to hold my urine for a little after i first feel the urge to urinate
d. I will determine which muscles to contract by stopping and starting my stream of
137. A nurse is providing prenatal teaching for a client who is scheduled for an amniocentesis.
Which of the following statements indicates that the client understands the teaching?
a. I need to have an enema before the test
b. I should urinate before the test
c. I will lie on my left side during the test
d. I will drink an oral glucose solution during the test
138. A nurse in an emergency department is caring for a client who reports cocaine use 1 hr ago.
Which of the following findings should the nurse expect?
a. Memory loss
b. Slurred speech
c. Elevated temperature
● Dizziness, tremor, blurred vision, seizures, fever, tachycardia, hypertension
139. A nurse is assessing the heart sounds of a client who has acute pericarditis. Which of the
following clinical manifestations is an expected finding for this client?
a. Report of occipital headache
b. Scratchy, high pitched sound upon chest auscultation
c. ECG demonstrates a depressed ST segment
d. White, diffuse peritonsillar pustules
140. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel
syndrome. Which of the following recommendations should the nurse include?
a. Increase intake of foods high in gluten
b. Consume food high in bran fiber
c. Sweeten foods with fructose corn syrup
d. Increase intake of milk product
● Limit gas forming foods, caffeine, alcohol. Encourage high fiber and fluids
141. A nurse is admitting an older adult client who is transferring from another facility. The nurse
notes pressure ulcers on the client’s coccyx and abrasions around the wrists. Which of the
following actions should the nurse take to address the suspicions of elder abuse?
a. Inform the transferring agency of the client’s condition.
b. Privately interview the client about her condition.
c. Notify risk management
d. Contact the family regarding the client’s condition.
142. A nurse is caring for a client following a stroke. The client has right-sided weakness and
facial drooping. Which of the following nursing actions is the priority?
a. Maintain NPO status for client(ABC)
b. Change client's position every 2 hours
c. Perform range-of-motion exercises to client’s extremities.
d. Place the clients right hand in supination position.
143 . A community health nurse is teaching a client who has type 1 diabetes mellitus and is 10
weeks of gestation about managing diabetes during pregnancy. Which of the following
statements by the client indicates an understanding of the teaching?
a. “I will decrease my protein intake during the third trimester”( increase protein for basic
b. “ I will need to increase my insulin doses later in my pregnancy”
c. “I will increase my carbs at breakfast and limit them the rest of the day”
d. “I will decrease my calorie consumption during the first trimester”(increase calorie)
144. A home health nurse is preparing to assess a client who reports tingling around the mouth
and laxative use at least once daily. Which of the following assessments should the nurse
a. Test the client for Trousseau’s sign
b. Assess the client’s skin turgor
c. Check the client’s motor strength
d. Measure the client’s pupil size [Show Less]