West Coast University NURSING 493 Priority 3 Exam. Questions With Answers.b. BUN 16 mg/dL (Normal 10-20)
c. PT 12.2 seconds (Normal 11-14)
d. Fasting blo... [Show More] od glucose 103 mg/dL
180. A nurse is admitting a client who has schizophrenia. The client states, “I’m hearing voices.” Which of
the following responses is the priority for the nurse to state?
a. “How long have you been hearing the voices?”
b. “What are the voices telling you?”
c. “Have you taken your medication today?”
d. “I realize the voices are real to you, but I don’t hear anything.”-
Last Priority - Taken last Tuesday.
1. A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel
(AP) telling the client, “If you don’t eat, I’ll put restraints on your wrists and feed you.” The nurse should
intervene and explain to the AP that this statement constitutes which of the following torts?
b. Battery- physical
c. Assault- verbal
2. A nurse is providing discharge instructions to the parent of a newborn. Which of the following statement by
the parent indicates an understanding of the teaching?
a. I will suction my baby’s mouth before I suction his nose.
b. I will lubricate the tip of the syringe with water prior to suction his nose.
c. I should insert the syringe into the center of his mouth.
d. I should compress the bulb after inserting it into the mouth.
3. A nurse is providing discharge teaching about car seat safety to a parent of a newborn. Which of the
following statements by the parent indicates an understanding of the teaching?
a. I will place my baby in a forward- facing car seat in my back seat (facing the rear)
b. I can place my baby in the front seat with the airbag turned off. (dont put newborn in front)
c. I will position my baby at a 45 degree angle in the car seat.
d. I can turn my baby car seat around when she weighs 15 pounds.
4. A nurse is planning care for a client who is in labor and has gonorrhea. Which of the following actions
should the nurse include in the plan for delivery?
a. Instill erythromycin ointment into the newborn's eye
b. Apply miconazole vaginal cream to the mother prior to delivery
c. Give oral sulfadiazine to the mother prior to delivery
d. Administer penicillin G procaine IM to the newborn
5. A nurse is planning care for a client who has small-bore NG feeding tube in the jejenum. Which of the
following is an appropriate action for the nurse to take to confirm placement?
a. Instill two drops of blue food coloring formula
b. Review an abdominal x-ray report.
c. Verify the glucose level aspirated content.
d. Auscultate for bubbling sound while injecting air through the tube.??? - i chose this but ima dohle
check , i thought about verifying the placement at the moment
6. A charge nurse delegates to an AP the task of ambulating a client. At the end of the shift, the nurse discovers
the client has not been ambulated. Which of the following actions should the nurse take first?
a. Supervise the AP performing the task
b. Remind the AP of her assigned tasks.
c. Evaluate why the client was not ambulated. Asses the situation first. Yes. assess first
d. Ambulate the client on behalf of the AP.
Rationale: Care for the client comes first, so ambulate the patient because AP did not. Then you can
investigate why AP did not do the task.
7. A nurse is caring for a client who has prescription for lactated ringer’s IV 4080/mL24hr. The nurse should
set the IV infusion pump to deliver how many mL/hr to administer half of the total volume in the first 8 hr?
Half = 2040 which need to be administered in 8hrs. So 2040ml/8hr = 255ml/hr
8. A nurse is providing teaching to a client who DM about glycosylated hemoglobin blood test. Which of the
following statement by the client indicated an understanding of this test?
a. I will need to drink a glucose solution to get an accurate result
b. I will need to fast prior to taking this test not necessary
c. I will use the result of this test daily to modify my insulin dosage.
d. I will use this test to monitor how well I control my blood glucose.
9. A nurse is caring for a client who has CVC and develops an air embolism. Which of the following actions
should the nurse take?
a. Place the client in a left lateral trendelenburg position.
b. Prepare the client for chest tube insertion (I put this one. -Jackie)
c. Instruct the client to perform valsalva maneuver
d. Remove the client catheter.
Rationale: Page 98 ATI Med Surg Book.
10. A nurse is assessing a client who had a colostomy 24 hr ago. Which of the following finding is priority?
a. THe client reports a pain level of 6
b. The stoma appears dark purple in color
c. The colostomy has had no output
d. The client refuses to look at the colostomy
Rationale: Says notify provider when you see dark purple color which may indicate blood supply is
11. A nurse is caring for a client who has new prescription for enalapril. The client report tingling and
swelling around the mouth 1hr after receiving the medication. Which of the following actions should the
nurse take first?
a. Notify the rapid response team
b. Obtain IV access.???? - whats that drug that dialtes brochionles that are constricted in case of an
anaphylatci RXN ? i thought about that thats why i chose this.
c. Document findings
d. Elevate the lower extremity.
12. A nurse is admitting a client who is to undergo paracentesis for removal of ascetic fluid. Which of the
following actions should the nurse take?
a. Ensure the client has a full bladder just prior to the procedure
b. Weigh the client before and after the procedure
c. Administer a low-volume hypertonic enema the night before the procedure
d. Place the client in a side-lying position for the procedure
Rationale: Paracentesis is a procedure done to drain ascites fluid in the abdominal wall using a trocar and a
needle. Decrease in weight can be a data to assess if procedure has been effective to reduce weight and
remove ascites fluid in the abdominal wall.
13. A nurse is admitting a client who tells the nurse he has brought a copy of his advance directives. Which of
the following actions should the nurse take?
a. Place a copy of the document in the client's medical record.
b. Request a social worker to review the document with the client (social worker does not need to
c. Ask the client to keep the document in his bedside table. (store it in a safe place)
D. Have the provider approve the document. (does not need to be approved by MD)
14. A nurse is providing preop teaching to a client who is scheduled for uterine surgery and asks about the
reason for the indwelling urinary catheter. Which of the following responses should the nurse make?
a. The catheter will be used to administer pain medication after surgery. (not used for pain
b. The catheter will decompress your bladder during surgery.
c. The catheter will decrease the risk for UTI from surgery. (risk for UTI)
d. The catheter will immobilization after surgery.
15. A nurse is discharging a client who has a colostomy. The client states that she would like to use her
moisturizing soap to clean around the stoma. Which of the following responses by the nurse is appropriate?
a. It is acceptable to use this soap if it makes you comfortable.
b. Lubricants in moisturizing soaps can interfere with adhesion of the appliance
c. You may want to try other soaps to determine what is the best to clean around the stoma
d. Use of moisturizing soaps can contribute to skin infections. (I put this one -Jackie)
Rationale: Page 240 of Funds ATI book Moisturizing soap can interfere with adherence of pouch.
16. 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. RR 26/min- 30 - 60 is normal they can be is respiratory distress ABCS
b. Pulse 140/min
c. Abdominal breathing- they are normally abdominal breathers
d. Closed anterior fontanel
Rationale: page 7 peds 2016 Newborn to 1 year old: RR= 30-35/min
17. 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” (can be brief that sometimes they are
mistaken for daydreaming and may not be detected for months)
b. “The child usually has an aura prior to onset”
c. This type of seizure last 30-60 sec” (begin and end abruptly)
d. “This type of seizure has a gradual onset” (generalized onset)
18. A nurse is providing teaching about crutch safety to a client. Which of the following client actions indicates
an understanding of the teaching?
a. The client leans on both crutches to support body weight. (no)
b. The client places the crutches 30cm (12in) to the front and side of each foot while standing (6in)
c. The client flexes her elbows 10 degree when supporting weight by using the handgrips. (30deg)
d. The client keeps her axillae free of pressure. (yes use your hand for pressure)
19. A nurse is assessing a client who received a Mantoux skin test 72hr ago for TB screening. Which of the
following findings indicates a positive test?
a. An area of ecchymosis
b. A blister like area
c. An elevated hardened area.
d. A cool, blanched area.
Rationale: Page 136 of MEDSURG ATI BOOK. An induration (palpable, raised, hardened area) of 10 mm or
greater in diameter indicates a positive skin test.
20. A nurse is caring for a client who has a chest tube drainage. Which of the following findings indicates the
nurse the presence of an air leak?
a. Gentle bubbling in the suction chamber
b. Continuous bubbling in the water seal chamber
c. Fluid rising with inspiration and falling with expiration in the water seal chamber
D. Serosanguineous fluid in the drainage collection chamber.
Rationale:ATI Med Surg book page 106. Monitor the water seal chamber for continuous bubbling (air leak
finding). If observed, locate the source ofthe air leak, and intervene accordingly (tighten the connection,
replace drainage system).
21. A nurse is admitting a client to a med-surg unit. When performing medication reconciliation for the client.
Which of the following actions should the nurse take?
a. Compare new prescription with the list of medications the clients reports.
b. Encourage the client to make his own list after he returns to his home.
c. Exclude nutritional supplements from the list of medication the clients report
d. Include any adverse effects of the medication the client might develop.
22. A nurse is caring for a toddler who has cancer and is experiencing stomatitis from chemotherapy. Which
of the following intervention should nurse implement?
a. Apply viscous lidocaine.
b. Provide soft, nanacidic food
c. Give peroxide mouth washes.
d. Administer antiemetics
23. A nurse is teaching the family of an infant who has decreased cardiac output to congenital heart disease.
Which of the following instruction should the nurse include in the teaching?
a. Observe for manifestations of hunger in order to feed the infant before crying occurs keep
crying to a minimum, crying increases workload of heart
b. Bathe the infant and change the bed linens daily to reduce the risk of infection.
c. maintain the infant in supine position when sleeping.
d. Perform infant care activities frequently and intermittently throughout the day.
24. A nurse is providing teaching to a parent of a child who has varicella. Which of the following statements
should the nurse include in the teaching?
a. “Your child can return to school after a negative titer result.”
b. “Your child can return to school 24 hours after beginning antibiotics.”
c. “Your child can return to school once the lesions have crusted over.”
d. “Your child can return to school once the fever has subsided. [Show Less]