NR 452 VATI EXIT RN Comprehensive Predictor 2019 180 Questions and Answers UPDATED 2023
VATI- RN COMPREHENSIVE ASSMT -180 QUESTIONS
1. A nurse on a
... [Show More] mental health unit is admitting a client who has posttraumatic stress disorder.
Which of the following findings should the nurse expect?
A. Talks continuously about the event
B. Preoccupied with having a serious illness
C. Has difficulty concentrating on a task
D. Experiences frequent grandiose thoughts
2. A nurse is administering a scheduled medication to a client. The client reports that the
medication appears different than what they take home. Which of the following responses
should the nurse make?
A. "Did the doctor discuss with you that there was a change in this medication? "
B. "Do you know why this medication is being prescribed for you?"
C. "I will call the pharmacist now to check on this medication "
D. "I recommend that you take this medication as prescribed"
3. A nurse is assessing a client who is in skeletal traction for a fractured left tibia. The nurse
should Identify that which the following findings indicates altered tissue perfusion of the
affected extremity?
A. Purulent drainage at the site
B. Faint pedal pulse of left leg
C. Pain with movement of the left great toe
D. Warm skin temperature distal to pin site
4. 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 decrease my daily protein intake to 15 grams per day"
B. "I will use ibuprofen as needed to control abdominal pain"
C. "I will take sucralfate with meals three times per"
D. "I will avoid food and beverages that contain caffeine"
5. A nurse is caring for a client who is in the advanced stage of amyotrophic lateral sclerosis
(ALS). Which of the following referrals is the nurse's priority?
A. Occupational therapist
B. Social worker
C. Speech-language pathologist
D. Psychologist
6. A nurse administers digoxin 0.125 mg PO to an adult client. For which of the following
findings should the nurse notify the provider?
A. Constipation for 2 days
B. Potassium level 4.2 mEq/L
C. Digoxin level 1 ng/mL ** normal levels 0.5- 2.0
D. Apical pulse 58/ min
7. A nurse is updating the plan of care for a client who has an exacerbation of psoriasis. Which
of the following interventions should the nurse include in the plan?
A. Discontinue ultraviolet light therapy if lesions become itchy
B. Cover lesions with an occlusive dressing after applying a corticosteroid.
C. Scrub external lesions with a pumice stone
D. Instruct the client to add rubbing alcohol to bath water
8. A nurse is verifying a record of informed consent for a client who scheduled for surgery.
Which of the following actions should the nurse take?
A. Provide Information on the informed consent form about the benefits of the surgery
B. Confirm the client's signature is authentic
C. Inform the client about the condition that requires treatment
D. Explain the procedure to the client before verifying informed consent.???
9. A nurse is caring for a client who requests the creation of a living will. Which of the
following actions should the nurse take?
A. Schedule a meeting between the hospital ethics committee and client
B. Determine the client's preferences about postmortem care
C. Evaluate the client's understanding of life sustaining measures
D. Request a conference with the client's family
10. A nurse in an emergency department caring for a toddler who has burns following a house
fire. Which of the following actions should the nurse take first?
A. Administer antibiotics prophylactically to prevent sepsis.
B. Determine the location and depth of the burns.
C. Calculate fluid replacement based on vital signs and urinary output.
D. Check the mouth for soot and smoky breath. ABC’S
11. A nurse is caring for an older adult client who has prescriptions for multiple medications.
Which of the following factors should the nurse identify as an age-related change that
increases the risk for adverse effects from medications?
A. Prolonged medication half-life
B. Increased medication elimination
C. Decreased medication sensitivity
D. Rapid gastric emptying
12. A nurse is caring for a client who is in a seclusion room following violent behavior. The
client continues to display aggressive behavior. Which of the following actions should the
nurse take?
A. Express sympathy for the client's situation.
B. Confront the client about this behavior.
C. Speak assertively to the client.
D. Stand within 30 cm (1 fu of the client when speaking with them.
13. A nurse is reviewing the medical record of a client who is requesting combination oral
contraceptives. Which of the following conditions in the client's history is a contraindication
to the use of combination oral contraceptives?
A. Hypocalcemia
B. Diverticulosis
C. Hyperthyroidism
D. Thrombophlebitis
14. A nurse is creating a plan of care for a female client who has recurrent urinary tract
infections. Which of the following interventions should the nurse include in the plan?
A. Wear loose-fitting underwear.
B. Take a bubble bath after intercourse
C. Drink four 240 mL (8 oz) glasses of water each day
D. Void every to 6 hr during the day. NO
15. A nurse is consulting a pharmacological reference about medication compatibility prior to
administering warfarin to a client. Which of the following medications should the nurse
identify as being incompatible with warfarin?
A. Magnesium hydroxide
B. Naproxen NSAID’S
C. Lisinopril
D. Propranolol
16. A nurse in an emergency department is caring for a client following a motor-vehicle crash.
The client's Glasgow coma scale rating is 15. Which of the following findings should the nurse
expect?
A. The withdraws from pain.
B. The client is oriented times three.
C. The dent is unable to obey commands non.
D. The client opens eyes to sound.
17. A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal
bleeding. The nurse speaks a different language than the client. The client's partner and 10-
year-old child are accompanying her. Which of the following actions should the nurse take to
gather the client’s admission data?
A. Request a female interpreter through the facility
B. Ask nursing student who speaks the same language as the client to translate
C. Allow the client’s partner to translate
D. Have the client’s child translate
18. A nurse is planning care for a client who is recovering from an acute myocardial infarction
that occurred 3 days ago. Which of the following interventions should the nurse Include?
A. Perform an ECG every 12hr.
B. Place the client in a supine position while resting.
C. Draw a troponin level every 4hr.
D. Obtain a cardiac rehabilitation consultation.
19. A nurse in the infectious disease division of the local health department is caring for a
client. Which of the following infections should the nurse identify should be reported to the
health department?
A. Clostridium difficile
B. Human papilloma virus
C. Herpes simplex virus
D. Chlamydia trachomatis
20. A nurse is administering an intradermal injection for allergy testing to a client. Into which
of the following sites should the nurse inject the medication? (You will find hot spots to select
in the artwork below. Select only the hot spot that corresponds to your answer
21. A nurse is caring for a client who has compartment syndrome following the application of
a cast to the leg. Which of the following actions should the nurse take?
A. Apply ice to the extremity
B. Check the client’s pedal pulses.
C. Administer a dose of antiemetic medication
D. Position the client’s leg above the level of the heart
22. A nurse is caring for a client who speaks a language different from the nurse. Which of the
following actions should the nurse take?
A. Review the facility policy about the use of an interpreter.
B. Request a family member or friend to interpret information for the client.
C. Direct attention toward the interpreter when speaking to the client.
D. Request an interpreter of a different sex from the client.
23. A nurse is providing discharge instructions about newborn safety to a client who is 2 days
postpartum. Which of the following instructions should the nurse include?
A. Change smoke detector batteries every other year.
B. Use a car seat when traveling by airplane.
C. Place a plastic waterproof sheet over the crib bedding.
D. Lay the baby on his stomach to nap during the daytime.
24. A nurse manager is reviewing the steps of the progressive discipline process prior to
counseling a staff member who exhibits unprofessional behavior. Identify the sequence of
steps the nurse manager should plan to take in response to the staff members conduct (Move
the steps into the box on the right placing them order of performance. Use all the steps)
Set up a meeting to speak the staff member about the behavior
Verbally remind the staff member of the expected chances
Give the staff member a written warning about the behavior
Suspend the staff member from work for several days
Dismiss the staff member from employment at the
25. A nurse is assessing a client who has a prescription for hydrocodone PRN. Which of the
following adverse effects should the nurse identity as priority for withholding this medication
and notifying the provider?
A. Hypotension
B. Nausea
C. Constipation ** normal side effect
D. Urinary retention
26. A nurse is initiating bladder retraining for a client who has urge urinary incontinence.
Which the following instructions should the nurse give the client?
A. "Take your diuretic medication with your evening meal"
B. "Decrease your intake of cranberry juice"
C. "Plan to urinate every 3 hours while you are awake"
D. "Limit your fluid intake to 500 per day"
27. A nurse is teaching participants at a community center about advance directives. Which of
the following information should the nurse include in the teaching?
A. A client must create a do not resuscitate order when completing advance directives.
B. A health care surrogate makes health care decision when the client is no longer able.
C. Advance directives cannot be changed once implemented.
D. Assigning a health care surrogate requires legal consultation.
28. A nurse is caring for a client who has bipolar disorder. Which of the following behaviors
should the nurse identify indicating the client is experiencing mania?
A. The client speaks using word salad.
B. The client speaks using echopraxia.
C. The client is socially withdrawn.
D. The client is easily distracted by external stimuli.
29. A nurse is caring for a client who has colon cancer and is terminally ill. The client states, "I
can't believe I'm going to die." Which of the following statements should the nurse make?
A. "It might be comforting to pray for spiritual assistance."
B. "Your doctor will make sure you won't be in much pain "
C. "Tell me what is important to you right now."
D. "I felt the same way you're feeling when my mother died"
30. A home health nurse is teaching a new parent about caring for his 1-week-old infant.
Which of the following statements by the client indicates an understanding of the teaching?
A. "I will avoid picking up my baby too often to keep from spoiling him will"
B. "I will place a ticking clock nearby to soothe my baby throughout the day"
C. "I will hang a pastel-colored mobile 24 inches above my baby's crib. "
D. "I can use a firm pillow to prop up the bottle when feeding my baby. "
31. A nurse is assessing a client who is receiving daily aspirin therapy. The nurse should
identify that which of the following findings might indicate an allergic reaction to this
medication?
A. Weight gain
B. Blurred vision
C. Difficulty swallowing
D. High blood pressure
32. A nurse is creating a plan of care for a newly admitted client who has obsessivecompulsive disorder. Which of the following interventions should the nurse include?
A. Discourage the client from exploring irrational fears.
B. Provide negative reinforcement for ritualistic behaviors.
C. Allow the client enough time to perform rituals.
D. Give the client autonomy in scheduling activities.
33. A nurse is planning care for a school-age child who is 4 hr postoperative following
appendicitis. Which of the following actions should the nurse include in the plan of care?
A. Give cromolyn nebulized solution every 8 hr.
B. Offer small amounts of clear liquids 6 hr following surgery.
C. Apply a warm compress to the operative site once daily.
D. Administer analgesics on a scheduled basis for the first 24 hr.
34. A nurse is caring for a client admitted for alcohol use disorder who reports using alcohol to
deal with stress. Which of the following actions should the nurse take to assist the client in
maintaining self-control of the behavior?
A. Give positive feedback to the client for using adaptive strategies.
B. Discuss strategies with the client to reduce alcohol consumption gradually.
C. Provide the client with periods of alone time for reflection in their behavior.
D. Have the client’s partner assume responsibility for monitoring the client’s alcohol intake.
35. A nurse is providing dietary teaching to a client who has hyperlipidemia. The nurse should
include in the teaching that which of the following oils contains the lowest amount of
saturated fats?
A. Canola oil
B. Olive oil
C. Palm oil
D. Coconut
36. A nurse is teaching a childbirth education class and is discussing sexual intercourse during
pregnancy. Which of the following statements should the nurse make?
A. "Frequent intercourse increases the risk for miscarriage in early pregnancy"
B. "You should limit the frequency of intercourse after 34 weeks of pregnancy"
C. "Your sexual desire might increase during the first trimester of pregnancy"
D. "The female superior position can be used during the third trimester of pregnancy"
37. A nurse is caring for a client who has acute exacerbation of multiple sclerosis. Which of
the following prescriptions should the nurse expect the provider to prescribe?
A. Atorvastatin
B. Enoxaparin
C. Interferon beta-1a
D. Amoxicillin
38. A nurse caring for a client who is labor and receiving oxytocin. Which of the following
findings indicates that the nurse should increase the rate of infusion?
A. Urine output of 20mL / hr ??
B. Montevideo units consistently 300 mmHg
C. Contractions every 5 min that last 30 seconds
D. FHR pattern with absent variability
39. A nurse is providing dietary teaching to a client who had an exacerbation of COPD. Which
of the following information should the nurse include in the teaching?
A. "While eating, you should drink liquids frequently. "
B. "During meals, you should eat foods with a high-calorie content first."
C. "You should eat hot foods to reduce your sense of fullness during a meal"
D. "Lunch should be your largest meal of the day"
40. A nurse is providing teaching about the administration of gastrostomy tube feeding to the
parents of a school age child. Which of the following Instructions should the nurse include?
A. Administer the feeding over 30 min
B. Place the child in a supine position after the feeding
C. Warm the formula in the microwave prior to administration
D. Change the feeding bag and tubing every 3 days
41. A nurse in a community clinic is caring for a client who requests assistance with smoking
cessation. The nurse should expect a prescription for which of the following medications?
A. Chlordiazepoxide
B. Clonidine
C. Bupropion
D. Naltrexone
42. A newly licensed nurse is unsure if an assigned task is within their scope of practice.
Which of the following resources should the nurse consult?
A. Written prescription the provider
B. Verbal direction from the nurse manager
C. State Nurse Practice
D. Institutional policies and procedures
43. A nurse is providing discharge teaching about car seat safety to a parent of a newborn.
Which of following statements by the parent indicates an understanding of the teaching?
A. "I will position my baby at a 45- degree angle in the car seat."
B. "I will place my baby in a forward-facing car seat in my back seat"
C. "I can place my baby in the front seat with the airbag turned off"
D. "I can turn baby's car seat around when she weighs 15 pounds"
44. A nurse is assessing a client who has heart failure and is prescribed a 2.000mL / 24 hr fluid
restriction. Which of the following findings should the nurse report to the provider?
A. Watery stools of 400 mL in 8 hr ???
B. Urinary output of 420 mL in 8 hr ****420 x 3= 1260 – 2,000 retaining 740 ml x day
C. Oral intake of 300 mL in 8 hr
D. Intravenous intake of 240 mL in 8 hr
45. A nurse is caring for a client who is postoperative immediately following a cardiac
catheterization with a right femoral approach Which the following actions should the nurse
take?
A. Elevate the head of the client’s bed to 450
B. Instruct the client to flex the right every 30 min
C. Assess the client's peripheral pulses every 15 min
D. Change the client's dressing 4 hr following the procedure
46. A nurse is reviewing the cardiac rhythm of a client who is on continuous ECG monitoring.
Which of the following findings should the nurse identify as an indication of ventricular
tachycardia?
A. QRS complexes wider than 0.15 seconds
B. P-wave present with every QRS complex
C. PR interval of 0.24 seconds
D. Sawtooth shaped P waves
47. A nurse is providing teaching to a client who has multiple sclerosis. Which of the following
statements should the nurse include in the teaching?
A. "Establish a voiding schedule by urinating once every 4 hours"
B. "Limit your daily intake of high-fiber foods"
C. "Avoid exercises that increase your body temperature"
D. "Wear an eye patch over one eye for an entire day before switching"
48. A nurse is providing preoperative teaching about patient-controlled analgesia (PCA) to a
client. Which of the following statements should the nurse include the teaching?
A. "You can adjust the amount of pain medication you receive by pushing on the keypad."
B. "The PCA will deliver a double dose of medication when you push the button twice."
C. "Continuous PCA infusion is designed to allow fluctuating plasma medication levels."
D. "You should push the button before physical activity to allow maximum pain control."
49. A nurse realizes that the wrong medication has been administered to a client. Which of
the following actions should the nurse take first?
A. Fill out an incident report
B. Report the incident to the nurse manager
C. Measure the client's vital signs
D. Notify the provider
50. A nurse is reviewing the facility's safety protocols concerning newborn abduction with the
parent of a newborn. Which of the following client statements indicates an understanding of
the teaching?
A. Staff will apply identification bands to my baby after her first bath.
B. "I will not publish a public announcement about my baby's birth."
C. I can remove my baby's Identification band as long as she is in my room.
D. "I can leave my baby in my room while I walk in the hallway
51. A nurse is assessing a client who immediately postoperative following a subtotal
thyroidectomy. The nurse observes tetany. Which of the following medications should the
nurse expect to administer?
A. Potassium chloride
B. Sodium phosphate
C. Sodium bicarbonate
D. Calcium gluconate
52. A nurse is providing teaching to a client who is to begin external radiation therapy for
cancer. Which of the following Information should the nurse include?
A. You might experience altered taste sensations
B. Wash your skin thoroughly with a washcloth after each treatment
C. Wear a binder over the radiation.
D. Use rubbing alcohol to remove the ink markings.
53. A nurse is caring for a client who is 12 hr postoperative following aorta femoral bypass
surgery. Which of the following findings should the nurse expect in the affected extremity?
A. Cool extremities
B. Pedal pulse of 2+
C. Throbbing pain
D. Capillary of 4 seconds
54. A nurse is preparing to administer an autologous blood product to a client. Which of the
following actions should the nurse take to identify the client?
A. Ensure that the client’s identification band matches the number on the blood unit.
B. Confirm the provider's prescription matches number on the blood component.
C. Match the client’s blood type with the type and cross match specimen.
D. Ask the client to state his blood type and the date of the blood donation.
55. A nurse is teaching a community health fair about electrical fire prevention. Which of the
following information should the nurse include the teaching?
A. Cover extension cords with a rug.
B. Remove the plug from the socket by pulling the cord.
C. Check for a tingling sensation around the cord to ensure the electricity working.
D. Use three-pronged grounded plugs.
56. A nurse is caring for a school-age child who has sickle cell anemia and is in vaso-occlusive
crisis. Which of the following actions should the nurse take?
A. Promote active range of motion exercise.
B. Prepare for a transfusion of platelets.
C. Increase oral fluid intake
D. Apply cold compresses to the affected areas.
57. A nurse is caring for a client who has a history of depression and is experiencing a
situational crisis. Which of the following actions should the nurse take first?
A. Teach the client relaxation techniques.
B. Notify the client’s support person.
C. Confirm the client’s perception of the event.
D. Help the client identify personal strengths.
58. A nurse is caring for a client who has gestational hypertension and is experiencing toxic
effects due to magnesium sulfate therapy. The nurse should anticipate administering which of
the following medications?
A. Calcium gluconate
B. Magnesium citrate
C. Potassium chloride
D. Sodium bicarbonate
59. A nurse is caring for a client who is in labor and requires augmentation of labor. Which of
the following conditions should the nurse recognize as a contraindication to the use of
oxytocin?
A. Shoulder presentation
B. Postterm with oligohydramnios ???
C. Chorioamnionitis
D. Diabetes mellitus
60. A nurse is caring for a client who is receiving brachytherapy for treatment of prostate
cancer. Which of the following actions should the nurse take?
A. Limit the client's visitors to 30 min per day
B. Discard the client's linens in a double bag.
C. Cleanse equipment before removal from the client's room.
D. Discard the radioactive source in a biohazard bag.
61. A nurse is caring for a client who has a prescription for 1 unit of packed RBCs. Five minutes
after beginning the transfusion, the client becomes febrile with chills. After stopping the
transfusion, which of the following actions should the nurse take?
A. Place the blood bag in a biohazard bag before discarding.
B. Document the reaction in the medical record.
C. Administer epinephrine subcutaneously.
D. Infuse 500 mL lactated Ringer's IV. **only Normal saline is use with transfusions
62. A nurse is providing teaching to a client who is breastfeeding and experiencing
engorgement. Which of the following recommendations should the nurse include?
A. Apply warm compresses on the breasts before feedings.
B. Allow the infant to nurse on one breast per feeding,
C. Take aspirin to reduce pain and swelling.
D. Wear a tight-fitting underwire bra.
63. A nurse is providing teaching to the parent of a child who has a recently inserted central
venous access device. Which of the following statements by the child's family member
indicates an understanding of the teaching?
A. "Will replace the dressing in 24 hours with an occlusive dressing."
B. "If my child develops an elevated temperature. I will contact you."
C. "I can expect my child to resume playing sports within 48 hours."
D. "I should encourage a daily shower to keep the insertion site clean."
64. A nurse is caring for a client who tells the nurse that he feels he is being discharged from
the facility too soon. Which of the following state by the nurse demonstrates client advocacy?
A. "I know you will be able to recover faster at home."
B. "I will contact your insurance company to see if they will pay for you to be here longer."
C. "Your provider understands your illness and is acting according to your best interests."
D. "I will tell the provider about your concerns."
65. A nurse is planning care for a child who has neutropenia due to leukemia. Which of the
following interventions should the nurse include in the plan of care?
A. Monitor the child for indications of active bleeding.
B. Prepare the child for a platelet transfusion. W
C. Screen the child's visitors for active infections.
D. Initiate a low-protein diet for the child.
66. A nurse is assessing a client who is 30 min postoperative following an arterial
thrombectomy. Which of the following findings is the priority for the nurse to report?
A. Chest pain
B. Cool, moist skin
C. Incisional pain
D. Muscle spasms
67. A nurse is providing teaching to a client who has heart failure and a new prescription for
furosemide. Which of the following statements should the nurse make?
A. "Rise slowly when getting out of bed."
B. "Taking furosemide can cause you to be overhydrated."
C. "Eat foods that are high in sodium."
D. "Taking furosemide can cause your potassium levels to be high."
68. A nurse is teaching a client who had a left below-the-knee amputation 3 days ago. The
nurse should identify that which of the following statements by the client indicates an
understanding of the teaching?
A. "I will change the wrapping on my left leg once a day at home."
B. "I can elevate my left leg on a pillow while lying in bed."
C. "I should avoid moving the joints in my left leg."
D. "I might still experience the feeling of numbness and tingling in my left foot."
69. A nurse is helping to prepare a client in the operating room prior to a surgical procedure.
Which of the following actions should the nurse take?
A. Minimize conversation with the client to reduce anxiety.
B. Provide padding to the pressure point areas when positioning the client.
C. Leave the client's arms and legs uncovered until after the induction of anesthesia.
D. Remove the client's eyeglasses upon arrival to the operating room.
70. A nurse is preparing to measure the temperature of an infant. Which of the following
actions should the nurse take?
A. Place the tip of the thermometer under the center of the infant's axilla.
B. Pull the pinna of the infant's ear forward before inserting the probe.
C. Insert the oral thermometer in front of the infant's tongue
D. Insert the probe 3.8 cm (1.5 in) into the infant's rectum.
71. A nurse is assessing the grief response of a client whose child died 6 months ago. Which of
the following client statements should the nurse report to the provider as an indication of
major depressive disorder?
A. "I am unable to feel any joy since my child died."
B. "I am angry that my child died."
C. "know that I will be reunited with my child someday."
D. "I feel guilty because my child died."
72. A nurse is interviewing the partner of a client who was admitted in the manic phase of
bipolar disorder. The partner states. "I don't know what to do. Everything has been
happening so quickly." Which of the following responses by the nurse is therapeutic?
A. "You did the right thing by bringing your partner in for treatment."
B. "You should make sure your partner takes the prescribed medication."
C. "Can you talk about what was happening with your partner at home?"
D. "Why do you think your partner's symptoms are progressing so quickly"
73. A nurse in a clinic is assessing a 6-month-old Infant. Which of the following findings should
the nurse report to the provider?
A. Closed anterior fontanel ** posterior -closes around 2 months, anterior at 12-18 mths
B. Pulse 140/min
C. Abdominal breathing
D. Respiratory rate 26/min
74. A nurse is caring for a client who is recovering from an amputation of her right arm below
the elbow. Which of the following information should the nurse report to the occupational
therapist?
A. The client lives in a two-story home.
B. The client's parent is in a skilled nursing facility.
C. The client is allergic to penicillin
D. The client has two small children at home.
75. A nurse caring for a client who received a large amount of heparin IV in error. Which of
the following laboratory values should the nurse obtain?
A. Ferritin level
B. Albumin level
C. INR
D. aPTT
76. A nurse is performing an initial assessment of a newborn. Which of the following actions
should the nurse take to prevent any heat loss through conduction?
A. Evaluate respirations by observing the newborn's uncovered chest for 1 min.
B. Cover the scale with a warmed blanket before weighing the baby.
C. Place the newborn's crib away from of an air vent to perform the assessment.
D. Perform the assessment immediately after birth before removing amniotic fluid.
76. A client's partner tells a staff nurse that he overheard laboratory staff discussing the
results of the client's biopsy report while on the elevator Which of the following actions
should the nurse take?
A. Review confidentiality policies with laboratory employees.
B. Report the information to the charge nurse.
C. Contact the laboratory manager regarding the situation
D. Notify the facility's legal department
77. A nurse is teaching a client who has chronic low back pain about the use of alternative
therapy to manage pain. Which of the following statements by the client indicates an
understanding of the use of distraction?
A. "I should apply my heating blanket to my back to reduce tension."
B. "I will have electrodes inserted in my skin to treat the pain."
C. "I should jog every morning to improve my circulation."
D. "I will watch my favorite old movies when I want to reduce stress."
78. A nurse is teaching a client who has systemic lupus erythematosus (SLE). Which of the
following statements by the client indicates an understanding of the teaching?
A. "I will not be able to go for my daily walk."
B. "I will cleanse my skin using a mild soap."
C. "I should apply powder to my skin after showering."
D. "I should check my skin once weekly for rashes." ** need to be done daily
79. A nurse is teaching a group of clients who are planning to have bariatric surgery. Which of
the following statements by a client indicates an understanding of the teaching?
A. "I will consume 48 ounces of carbonated beverages daily prior to the surgery."
B. "I should reduce my daily caloric intake by 250 calories to lose 2 pounds each week after
surgery."
C. "I will need to lose 25 percent of my excess body weight prior to surgery.
D. "I should wait 30 minutes after eating solid foods to drink beverages following surgery."
80. A nurse is teaching a client who is trying to conceive. Which of the following should the
nurse instruct the client to increase in her diet to prevent a neural tube defect?
A. Iron
B. Calcium
C. Folate
D. Zinc
81. A nurse is caring for a client who is near the end of life and is on complete bed rest. The
client states that he needs to have a bowel movement. and the nurse offers a bed pan. The
client states. "I've always used the bathroom." Which of the following responses should the
nurse make?
A. "I will have the physical therapist ambulate you to the bathroom."
B. "You have to use the bed pan for your own safety."
C. "Make sure to use nearby furniture to support yourself when walking to the bathroom"
D. "Tell me what concerns you have about using a bed pan."
82. A nurse is reviewing laboratory data from a client who has chronic kidney disease. Which
of the following findings should the nurse expect?
A. Increased calcium
B. Increased bicarbonate
C. Increased creatinine
D. Increased hemoglobin
83. A nurse is obtaining a urine specimen from a client who has had an indwelling urinary
catheter for three days. Which of the following actions should the nurse take after collecting
the specimen?
A. Place the specimen in a biohazard bag for transport.
B. Wipe the outside of the specimen container with an alcohol swab.
C. Obtain the specimen from the drainage collection bag.
D. Remove gloves after labeling the specimen
84. 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. Vaccinate susceptible children and adults against smallpox.
B. Assess types, levels, and scopes of disasters.
C. Make quarantine preparations for those exposed to anthrax,
D. Participate in community drills and mock events.
85. A nurse is caring for several clients on a medical-surgical unit. For which of the following
nursing activities is it required that the nurse we use sterile gloves?
A. Performing tracheostomy care
B. Administering total parenteral nutrition through a central venous access device
C. Inserting an NG tube
D. Initiating IV access
86. A charge nurse is recommending postpartum clients for discharge following a local
disaster. Which of the following clients should the nurse recommend for discharge first?
A. A client who delivered precipitously 36 hr ago and has a second-degree perineal laceration
B. A 15-year-old client who delivered via emergency cesarean birth 1 day ago
C. A client who received 2 units of packed RBCs 6 hr ago for a postpartum hemorrhage
D. A 42-year-old client who has preeclampsia and a BP of 166/110 mm Hg
87. A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which
of the following findings should the nurse report to the provider?
A. Platelets 150,000/mm3
B. Erythrocyte sedimentation rate 75 mm/hr
C. Aspartate aminotransferase 10 units/L
D. WBC count 8,000/mm3
88. A nurse is discussing group treatment and therapy with a client. The nurse should include
which of the following as being a characteristic of a therapeutic group?
A. The group encourages clients to form dependent relationships.
B. The group encourages members to focus on a particular issue.
C. The group is organized in an autocratic structure.
D. The group must be led by a licensed psychiatrist.
89. A nurse is providing teaching about home safety to the adult child of an older adult client
who is postoperative following knee replacement surgery. Which of the following instructions
should the nurse include?
A. Place a throw rug over electrical cords.
B. Encourage the client to avoid wearing shoes at home,
C. Mark the edges of the doorway to the house with tape.???
D. Ensure that area rugs have rubber backs.
90. A nurse is assessing a client who is receiving packed RBCs. Which of the following findings
indicates fluid overload?
A. Dyspnea
B. Thready pulse
C. Low-back pain
D. Hypotension
92. 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 both wrists. Which of
the following actions should the nurse take to address suspicions of elder abuse?
A. Contact the family regarding the client's condition
B. Inform the transferring agency of the client's condition.
C. Notify risk management.
D. Privately interview the client about the injuries.
93. 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 eat which of the following foods
while taking this medication?
A. Smoked salmon
B. Pepperoni pizza
C. Whole grain bread
D. Avocados
94. A nurse is caring for an adolescent who has sickle-cell anemia. Which of the following
manifestations indicates acute chest syndrome and should be immediately reported to the
provider?
A. Substernal retractions
B. Sneezing
C. Hematuria
D. Temperature 37.9°C(100.2°F)
95. A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which
of the following actions should the nurse take?
A. Notify the nursing supervisor about the suspected alcohol use.
B. Inform another nurse on the unit about the suspected alcohol use.
C. Confront the nurse about the suspected alcohol use.
D. Ask the nurse to finish administering medications and then go home. [Show Less]