ati fundamentals

Question 1

1.A nurse is planning care for a group of clients. Which of the following tasks should the nurse
delegate to an assistive personnel?
A. Changing the dressing for a client who has a stage 3 pressure injury
B. Determining a client’s response to a diuretic
C. Comparing radial pulses for a client who is postoperative
D. Providing postmortem care to a client

Answer 1

Providing postmortem care to a client

Question 2

A nurse is conducting a health assessment for a client who takes herbal supplements. Which
of the following statements by the client indicates an understanding of the use of the
supplements?
A. I take ginkgo biloba for a headache
B. I take echinacea to control my cholesterol
C. I use ginger when I get car sick
D. I use garlic for my menopausal symptoms

Answer 2

C. I use ginger when I get car sick

Question 3

A nurse is caring for a client who has influenza and isolation precautions in place. Which of
the following actions should the nurse take to prevent the spread of infection?
A. Wear a mask when working within 3 feet of the client
B. Administer metronidazole
C. Don protective eyewear before entering the room.
D. Place the client in a negative airflow room.

Answer 3

Wear a mask when working within 3 feet of the client

Question 4

A nurse obtains a prescription for wrist restraints for a client who is trying to pull out his NG
tube. Which of the following actions should the nurse take?
A. Attach the restraints securely to the side rails of the client’s bed.
B. Apply the restraints to allow as little movement as possible
C.Allow room for two fingers to fit between the clients skin and the restraints
D.Remove the restraints every 4 hr.

Answer 4

Allow room for two fingers to fit between the clients skin and the restraints

Question 5

A nurse is admitting a client who has tuberculosis. Which of the following types of
transmission precautions should the nurse plan to initiate?
D. Contact
A. Droplet
B. Airborne s
C. Protective environment

Answer 5

Airborne

Question 6

A nurse in a well-child clinic receives a telephone call from a parent who states that their
child accidentally swallowed paint thinner. The child is awake and alert. Which of the
following responses should the nurse make?
A. Have your child drink one large glass of water.
B. Hang up and call a poison control center hotline.
C. Bring your child into the clinic later today.
D. Induce vomiting in your child with syrup of ipecac.

Answer 6

Have your child drink one large glass of water.

Question 7

A nurse is documenting a client’s medical record. Which of the following entries should the
nurse record.
A. Oral temperature slightly elevated at 0800
B. Administered pain medication
C. Incision without redness or drainage
D. Drank adequate amounts of fluid with meals

Answer 7

Administered pain medication

Question 8

A nurse is providing oral care for a client who is unconscious. Which of the following
actions should the nurse take?
A. Place the client in a side-lying position.
B. Brush the clients teeth daily
C. Apply mineral oil to the client’s lips
D. Rinse the client’s mouth with an alcohol-based mouthwash

Answer 8

. Place the client in a side-lying position

Question 9

A nurse is collaborating with a risk management team about potential legal issues involving
client care. The nurse should identify which of the following situations is an example of
negligence?
A. A nurse administers a medication without first identifying the client.
B. An assistive personnel discusses client care in the facility cafeteria with visitors
present.
C. A nurse begins a blood transfusion without obtaining consent.
D. An assistive personnel prevents a client from leaving the facility.

Answer 9

C. A nurse begins a blood transfusion without obtaining consent.

Question 10

. A nurse is collecting a sputum specimen for culture from a client who has a respiratory
infection. Which of the following actions should the nurse take?
A. Wear sterile gloves when collecting the specimen.
B. Offer the client oral hygiene after the collection
C. Collect the specimen in the evening.
D Collect 1 ml of sputum.

Answer 10

Offer the client oral hygiene after the collection

Question 11

A nurse is assessing an older client. Which of the following findings should the nurse
expect?
* Decreased sense of balanced
* Increased nighttime sleeping
* Heightened sense of pain
* Nighttime urinary incontinence

Answer 11

• Decreased sense of balanced

Question 12

A nurse is completing discharge teaching about ostomy care with a client who has a new
stoma. Which of the following instructions should the nurse include in the teaching? (select
all that apply)
* “Cut the opening of the pouch ⅛ of an inch larger than the stoma “
* “Place a piece a gauze over the stoma while changing the pouch”
* “Use povidone-iodine to clean around the stoma”
* “Empty the ostomy pouch when it becomes one-third full of contents”
* “Expect the
stoma to turn a purple-blue color as its heals”

Answer 12

“Cut the opening of the pouch ⅛ of an inch larger than the stoma “
* “Place a piece a gauze over the stoma while changing the pouch”
* “Use povidone-iodine to clean around the stoma”
* “Empty the ostomy pouch when it becomes one-third full of contents”

Question 13

A nurse is preparing to obtain informed consent from a client who speaks a different
language than the nurse. Which of the following actions should the nurse take?
* “Request that an assistive personnel interpret the information for the client”
“Use proper medical terms when giving information to the client”
“Offer written information in the client’s language”
“Avoid using gestures when speaking to the client”

Answer 13

“Offer written information in the client’s language”

Question 14

A nurse is teaching a client about home care equipment. Which of the following information
should the nurse include in the teaching? (select all that apply)
* “Avoid using wool blankets when receiving oxygen”
* “Keep the oxygen delivery system 0.6 m (2 feet) from any heat source”
“Check the oxygen delivery rate at least once a day”
“Align the middle of the ball in the flow meter with the line of the prescribed flow rate
“Keep the oxygen delivery system 0.6 m (2 feet) from any heat source”
* “Lay the oxygen tank flat when storing”

Answer 14

“Avoid using wool blankets when receiving oxygen
Check the oxygen delivery rate at least once a day”
“Align the middle of the ball in the flow meter with the line of the prescribed flow rate”

Question 15

A nurse is planning care for a client who reports insomnia. Which of the following actions
should the nurse perform shortly before bedtime?
* Provide a late supper.
* Offer a wet washcloth for the client to wash her face
* Perform range-of-motion exercises
* Prepare hot cocoa or tea for the client

Answer 15

Provide a late supper.
* Offer a wet washcloth for the client to wash her face

Question 16

A nurse on a medical-surgical unit is receiving a change-of-shift report for four clients.
Which of the following clients should the nurse see first?
* A client who has acute abdominal pain of 4 on a scale from 0 to 10
* A client who has pneumonia and an oxygen saturation of 96%
* A client who has new onset of dyspnea 24hr after a total hip arthroplasty
* A client who has a urinary tract infection and low-grade fever

Answer 16

A client who has new onset of dyspnea 24hr after a total hip arthroplasty

Question 17

. A nurse is reviewing a client’s intake and output and notes the following: 0.9% sodium
chloride 600mL IV infusion, cefazolin 250 mg in dextrose 5% in water 100mL intermittent
IV bolus, 200mL emesis, 40mL voided urine, and 20mL urine from straight catheterization.
The nurse should record the client’s net fluid intake as how many mL? (Round the answer to
the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Answer 17

700 mL, the rest are output

Question 18

A nurse is discussing incident reports with a group of newly licensed nurses. The nurse
should include that which if the following requires the completion of an incident report?
* A client’s prescribed laboratory testing was not obtained
* A client withdrew consent for a procedure
* An oncoming nurse arrived to work late
* A nurse transfused a unit of packed RBCs in 2 hr

Answer 18

A client’s prescribed laboratory testing was not obtained

Question 19

A nurse is caring for a client who has a new prescription for negative-pressure therapy for a
chronic wound. The nurse is unfamiliar with the procedure. Which of the following
resources should the nurse consult to learn more about the intervention.
* The client’s plan of care
* The nurse practice act
* The material safety data sheet
* The policy and procedure manual

Answer 19

The policy and procedure manual

Question 20

A nurse is performing postural drainage with percussion and vibration for a client who has
cystic fibrosis. Which of the following actions should the nurse take?
* Cover the area of percussion with a towel.
* Instruct the client to exhale quickly during vibration
* Schedule postural drainage after meals
* Perform percussion over the lower back

Answer 20

Perform percussion over the lower back

Question 21

A nurse is preparing to administer diphenhydramine 20 mg orally to a 6-year-old child who
has difficulty swallowing pills. Available is diphenhydramine 12.5mg/5ml oral syrup.
Which of the following images indicates the correct number of mL the nurse should
administer? (round answer to the nearest whole number.)
Should be the first syringe 8ml

Answer 21

Should be the first syringe 8ml

Question 22

A nurse is admitting a client who is malnourished. The client states, “My wedding ring is
loose and I’m worried I will lose it if it falls off.”Which of the following is an appropriate
response by the nurse?
“ I will place it in your drawer so it won’t get lost.”
I can pin it to your hospital gown so you won’t lose it.”
“I will hold onto it until a family member can take it home.”
“I can put it in a locked storage unit for you.”

Answer 22

“I can put it in a locked storage unit for you.”

Question 23

A charge nurse is teaching a group of newly licensed nurses about the use of restraints. In
which of the following clinical situations should the nurse apply restraints?
* If the client is pacing in the hallway
* As a part of a fall prevention program
* At the request of the client’s family
* When the client poses a threat to self

Answer 23

• When the client poses a threat to self

Question 24

To ensure client safety, a nurse manager is planning to observe a newly licensed nurse
perform a straight catheterization on a client. In which of the following roles is the nurse
manager functioning?
* Case manager
* Client educator
* Client care provider
* Client advocate

Answer 24

• Client advocate

Question 25

A charge nurse in a long-term care facility is preparing an educational program about
delirium for newly hired nurses. Which of the following statements should the nurse plan to
include?
* “Delirium does not affect a client’s perception of her environment.”
* “Delirium does not affect a client’s sleep cycle.”
* “Delirium has an abrupt onset.”
* “Delirium has a slow progression.”

Answer 25

• “Delirium has an abrupt onset.”

Question 26

A nurse is speaking with a client who has recently received a diagnosis of a chronic illness.
The client states, “ The doctor must be wrong. I can’t be that sick”. The nurse should inform
the client that their reaction is an example of which of the following expected responses to
grief?
* Acceptance
* Denial
* Anger
* Depression

Answer 26

Denial

Question 27

. A Nurse on a medical-surgical unit is providing care for four clients. The nurse should
identify which of the following situations as an ethical dilemma?
* A surgeon who removed the wrong kidney during a surgical procedure refuses to take responsibility for her actions
* A client who has Crohn’s disease reports that his prescription drug plan will not pay for his medications.
* A client who has a new colostomy refuses to take instructions from the ostomy therapist because she “doesn’t like him.”
The family of a client who has a terminal illness asks that the provider not tell the client the diagnosis

Answer 27

The family of a client who has a terminal illness asks that the provider not tell the client the diagnosis

Question 28

A nurse is teaching a client about performing breast self-examinations. Which of the
following statements by the clients indicates an understanding of the teaching?
“I should perform my self-exam the week that my period starts”
“I should make different patterns on each breast when I do my self-exam.”
“I should use the palm of my hand to apply pressure to each breast.”
* “I should make circular motions with my fingertips under my arms.”

Answer 28

• “I should make circular motions with my fingertips under my arms.”

Question 29

9. A nurse is preparing to transfer a client who is partially weight bearing from the bed to the
   chair. Which of the following actions should the nurse take?
   * Keep his knees straight when moving the client
   * Position the chair next to the bed as a 90 degree angle
   * Stand with his feet together when lifting the client
   * Have the client bear weight on her stronger leg

Answer 29

• Have the client bear weight on her stronger leg

Question 30

A nurse is caring for a client following a laparoscopic cholecystectomy. The client has a
prescription for ondansetron 4mg IV bolus every 6hr PRN for nausea and vomiting. Identify
the sequence of steps the nurse should follow to administer the medication. ( Move the steps
into the box on the right, placing them in the order of performance. Use all the steps.)

• Perform hand hygiene.
  Select the injection port of the IV tubing closest to the client.
  Cleanse the injection port with an antiseptic swab.
  Aspirate for blood return.
  Inject the medication

Answer 30

Perform hand hygiene.
Select the injection port of the IV tubing closest to the client.
Cleanse the injection port with an antiseptic swab.
Aspirate for blood return.
Inject the medication

Question 31

A nurse is teaching a client who has diabetes mellitus about mixing regular and NPH
insulin.
Which of the following statements but the client indicates an understanding of the teaching
* I should wait 3 minutes after mixing the insulin to inject it
* I should draw up the NPH insulin before regular insulin
I should inject air into the vial of regular insulin first
* I should roll the vial of NPH insulin between my hands before drawing it up

Answer 31

i should roll the vial of NPH insulin between my hands before drawing it up

Question 32

A nurse is assessing the body temperature of an adult client using a temporal artery
thermometer. Which of the following actions should the nurse take? (Select all that apply)
* Slide the probe across the clients forehead
* Pull the clients pinna up & back
* Hold the client’s hair aside while performing the procedure
* Document the client’s temperature with “AX” next to the value
* Move the probe in a circular motion

Answer 32

Slide the probe across the clients forehead
Hold the client’s hair aside while performing the procedure

Question 33

A nurse is preparing to insert a peripheral IV catheter into the client’s arm. Which of the
following actions should the nurse take to help dilate the vein?
* Stroke the skin near the vein in an upward position
* Dangle the client’s arm over the edge of the bed
* Apply a cool compress to the vein for 10 min
* Instruct the client to flex their arm with the hand open

Answer 33

Dangle the client’s arm over the edge of the bed

Question 34

A nurse is preparing to suction a client’s tracheostomy tube. Which of the following actions
should the nurse plan to take?
Apple intermittent suction during catheter insertion
Suction the client’s airway for 20 seconds with each pass
Hyperoxygenate the client manually for 30 to 60 seconds before suctioning
Decrease suction pressure to 150 mm Hg if the oxygen saturation level drop during suctioning

Answer 34

Decrease suction pressure to 150 mm Hg if the oxygen saturation level drop during suctioning

Question 35

A nurse is assessing a client who received morphine for severe pain 30 mins ago. Which of
the following finding is the nurse’s priority?
* Last bowel movement was 3 days ago
* Reports pain of 8 on a scale of 0 to 10
* Distended bladder
* Respiratory rate 7/min

Answer 35

• Respiratory rate 7/min

Question 36

A nurse is caring for a client who has been treated multiple times for STIs. Which of the
following responses should the nurse take?
* “You must have too many sexual partners”
* “Why do you keep letting this happen?”
* “Let’s explore why this might be reoccurring”
* “Don’t you have access to condoms?”

Answer 36

• “Let’s explore why this might be reoccurring”

Question 37

A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair
and begins to experience a seizure. Which of the following actions should the nurse take
first?
* Move items in the room away from the client
* Turn the client onto their side
* Help the client lie on the floor
* Loosen the client’s clothing

Answer 37

Help the client lie on the floor

Question 38

A nurse is testing a client for conduction deafness by performing Weber’s test. Which of the
following actions should the nurse take when performing this test?
* Move a vibrating tuning form in front of the client’s ear canals one after the other
* Place the base of a vibrating tuning fork on the client’s mastoid process
* Place the base of a vibrating tuning fork on the top of the client’s head
* Count how many seconds a client can hear a tuning fork after it has been struck

Answer 38

Place the base of a vibrating tuning fork on the top of the client’s head

Question 39

A nurse is obtaining the medication history of a client who asks about taking ginkgo biloba.
The nurse should identify which of the following medications can interact adversely with
this supplement?
* Warfarin
* Albuterol
* Levothyroxine
* Atorvastatin

Answer 39

Warfarin

Question 40

A nurse is obtaining informed consent from a client who is scheduled for surgery. The client
states, “I don’t want to go through with the procedure.” Which of the following actions
should the nurse take?
* Discuss alternative treatments with the client
* Explain to the client the risks involved with not having the procedure
* Express approval of the client’s decision to not have the procedure
* Document the client’s decision in the medical record

Answer 40

Document the client’s decision in the medical record

Question 41

A nurse is providing teaching to a client about reducing the adverse effects of immobility.
Which of the following statements by the client indicates an understanding of the teaching?
· “ I will have my partner help me change position every 4 hours”
· “ I will remove my antiembolic stockings while I am in bed”
· “ I will hold my breath when rising from a sitting position”
· “ I will perform ankle and knee exercises every
hour.”

Answer 41

“ I will perform ankle and knee exercises every
hour.”

Question 42

A nurse is caring for a client who is postoperative and has a new prescription to advance her
diet to full to full liquids. Which of the following foods should the nurse offer the client as a
part of a full liquid diet?
· Oatmeal
· Applesauce
· Scrambled eggs
· Plain Yogurt

Answer 42

Plain Yogurt

Question 43

A nurse is preparing a client who has terminal cancer for discharge. Which of the following
questions should the nurse ask when assessing the client’s psychosocial history?
· “ What medications are you currently taking?”
· “ Are you experiencing any Pain?”
· “ Have any of your relatives been diagnosed with cancer?”
· “ What Techniques do you use to cope with stress?

Answer 43

What Techniques do you use to cope with stress?”

Question 44

A nurse is performing a skin assessment on an older adult client. Which of the following
findings should the nurse expect?
· Thickened outer layer of skin
· Increased skin elasticity
· Reduced sweat production
· Increased Production of oils

Answer 44

Reduced sweat production

Question 45

A nurse is caring for a client who begins to cry after receiving a diagnosis of cancer. Which
of the following responses should the nurse make?
· “ I would get a second opinion if I were you.”
· “ it might seem bad now, but things will get better.”
· “ it must be difficult for you to receive this kind of news.”
· I think you would benefit from speaking with our chaplain.”

Answer 45

“ it must be difficult for you to receive this kind of news.

Question 46

A nurse is preparing to obtain a health history from a client. Which of the following actions
should the nurse take?
· Use the client’s first name when initially meeting the client.
· Tell the client the purpose for collecting the information
Explain to the client the necessity of full disclosure of information.
· Avoid documenting direct quotes from the client as part of subjective data.

Answer 46

Tell the client the purpose for collecting the information.

Question 47

A nurse is caring for a client who has brain cancer and is transferring to hospice care. The
client’s son tells the nurse, “ I don’t know what to tell my dad if he asks how he is going to
die.” Which of the following is an appropriate response by the nurse?
“ Let’s talk more about your dad’s condition.”
“The social worker will help you answer those questions.”
· “ Try to help your dad enjoy this time as much as he can.”
· “ I think that you should discuss this with the hospice nurse.”

Answer 47

Let’s talk more about your dad’s condition.”

Question 48

A Nurse is preparing to administer several medications to a client. Which of the following
data should the nurse plan to use to confirm the client’s identity?
· The client’s room number
· The client’s admitting diagnosis
· The name of the client’s next of kin
· The client’s telephone number

Answer 48

The client’s telephone number or admitting dx

Question 49

A nurse is caring for a client who is prescribed a special diet. The client is concerned that he
does not have the resources to purchase the food he needs to adhere to the diet at home. The
nurse should notify which of the following members of the health care team.
· Social worker
· Occupational therapist
· Registered Dietician
· Primary care provider

Answer 49

· Social worker

Question 50

A nurse is teaching a newly licensed nurse about the care of a client who has a
methicillinresistant Staphylococcus aureus (MRSA) infection. Which of the following
statements by newly licensed nurse indicates an understanding of the teaching?
· “ I will place the client in a Private room.”
· “ I will remove my gown before my gloves after providing client care.”
· “ I will wear an N95 respirator mask when caring for the client.”
· “ I will tell the client’s visitors to wear a mask when they are within 3 feet of the
client.”

Answer 50

· “ I will place the client in a Private room.”

Question 51

A nurse is planning care for a client who reports having a latex allergy. Which of the
following interventions should the nurse include in the plan?
· Cover the blood pressure cuff with a stockinette.
· Wear powdered gloves when providing care to the client.
· Apply adhesive tape when securing an IV insertion site.
· Use plastic syringes for medication administration.

Answer 51

· Cover the blood pressure cuff with a stockinette.

Question 52

A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing
the client’s signature, the client states, “ I trust my doctor, but I don’t understand what is
meant by resecting my intestines.” Which of the following actions should the nurse take?
· Describe the surgery to the client.
· Notify the Provider.
· Complete an incident report
· Provide brochures about the procedure.

Answer 52

· Notify the Provider.

Question 53

A nurse is documenting client care. Which of the following abbreviations should the nurse
use?
· “ SQ” for subcutaneous
· “SS” for sliding scale
“BRP” for bathroom privileges
“OJ” for orange juice

Answer 53

“BRP” for bathroom privileges

Question 54

A nurse is preparing to bathe a client who has dementia. Which of the following actions
should the nurse take?
· Give detailed instructions for the client to follow.
· Complete the bath even if the client is in distress.
· Use distractions when bathing the client.
· Allow the client to select the temperature of the bath water

Answer 54

Use distractions when bathing the client

Question 55

A hospice nurse is caring for a client who has end stage cancer. Which of the following
interventions should the nurse include to promote the client’s dignity?
· Provide guided imagery exercises to the client.
· Refrain from discussing the client’s prognosis
· Suggest that the client keep a journal.
· Encourage the client to share their life story.

Answer 55

Refrain from discussing the client’s prognosis

Question 56

A nurse is caring for a client who has a closed wound drainage system. Which of the
following actions should the nurse take?
· Wear sterile gloves when emptying the container.
· Reset the container with the drainage port closed
· Connect the drain to high pressure suction.
· Press straight down on the container to create vacuum

Answer 56

Press straight down on the container to create vacuum

Question 57

A nurse receives a telephone prescription from a provider for a client who is experiencing
pain. Which of the following responses should the nurse make?
· “ Will you please spell the name of that medication for me?”
· “Let me clarify that you want the medication given qid, correct?”
· “ I will sign my name now and leave a space for you to sign your name.”
· “Let me provide you with the client’s medical record number for identification.”

Answer 57

“ Will you please spell the name of that medication for me?”

Question 58

During change of shift report, a nurse discovers she overlooked a prescription for a type and
cross-match of a client who is to have surgery the next day. Which of the following actions
should the nurse take first?
· Inform the provider of the delay in obtaining the type and cross-match.
· Obtain the client’s type and cross-match.
· Prepare an incident report for risk management.
· Document the incident in the client’s medical record.

Answer 58

Inform the provider of the delay in obtaining the type and cross-match.

Question 59

A Nurse is caring for client who has pneumonia. The nurse should recognize which of the
following should be discarded in a biohazard bag?
· An emesis basin filled with blood from severe coughing
· A bedpan containing diarrhea from a client who was receiving
antibiotics
· A disposable tissue containing expectorated sputum
· A calibrated toilet insert filled with urine.

Answer 59

· An emesis basin filled with blood from severe coughing

Question 60

A nurse is caring for a client who is receiving enteral feedings via NG tube. Which
following actions should the nurse take prior to administering the formula?
Check for gastric residual volume
Encourage the client to breathe deeply and cough.
· Flush the tube with sterile 0.9% sodium chloride irrigation.
· Encourage the client to take sips of water.

Answer 60

Check for gastric residual volume

Question 61

A nurse is caring for a client immediately following the insertion of an NG tube. Which of
the following indingd should indicate to the nurse that the tube is placed incorrectly?
* The client has a dry mouth
* The client is coughing
* The client has active bowel sounds
* The client is hiccupping

Answer 61

The client is coughing

Question 62

A nurse is inserting an NG tube for a client who requires gastric decompression. Which of
the following actions should the nurse take to verify proper placement of the tube?
* Assess the client for a gag reflex
* Measure the pH of the gastric
* Place the end of the NG tube in the water to observe for bubbling
* Auscultate 2.5 cm above the umbilicus while injecting 15 ml of water

Answer 62

• Measure the pH of the gastric

Question 63

A nurse is caring for a client who reports a ptain level of 5 on a scale from 0-10. The client
informs the nurse that pain meds are not an option for managing pain. Which of the
following is an appropriate response by the nurse?
* Would you like to get you a back massage?
* Why do you think pain med is not going to help you?
* You may take any herbal remedies you bring from home
* I’m sure it will work if you just give it a chance

Answer 63

Would you like to get you a back massage

Question 64

a nurse is caring for a client who has an extracellular fluid volume deficit. Which of the
following findings should the nurse expect?
* Bradycardia
* Postural hypotension
* Distended neck vein
* Dependent edema

Answer 64

Postural hypotension

Question 65

A nurse is caring for a client who is immunocompromised which of the following actions
should the nurse take?
* Use sterile gloves to provide perineal care
* Cleanse hands with an alcohol based hand rub before client contact
* Have the client apply a mask when children are visiting
* Place the client in a semi-private room

Answer 65

• Cleanse hands with an alcohol based hand rub before client contact

Question 66

A nurse is preparing to insert an iv catheter for a client following a right mastectomy.
Which of the following veins should the nurse select when initiating iv therapy?
* The radial vein on the left arm
* The cephalic vein in the left distal forearm
* The cephalic within on the back of the right hand
The basilic vein in the right antecubital fossa

Answer 66

• The cephalic vein in the left distal forearm

Question 67

A nurse is caring for a client who has urinary incontinence. Which of the following
interventions should the nurse take to prevent skin breakdown?
* Apply powder to the client perineal area
* Restrict client’s fluid intake
* Request a prescriptions for an indwelling urinary catheter
* Apply a moisture barrier ointment after perineal hygiene

Answer 67

Apply a moisture barrier ointment after perineal hygiene

Question 68

A nurse is caring for a client who was recently diagnosed with a terminal illness. The
client tells the nurse” I am looking forward to seeing my grandchildren grow up.” the nurse
should identify the client is experiencing which of the following stages of grief?
* Acceptance
* Bargaining
* Anger
* Denial

Answer 68

denial

Question 69

A nurse is teaching a client about the care and use of hearing aids. Which of the
following instructions should the nurse include in the teaching?
* Clean the hearing aid by soaking it in warm water
* Turn the hearing aid off and the volume down before insertion
* Replace the battery if the hearing aid emits a whistling sound
* Leave the battery in place when the hearing aid is not in use

Answer 69

• Turn the hearing aid off and the volume down before insertion

Question 70

A nurse is assessing a client’s eyes for accommodation. Which of the following actions
should the nurse take?
* Observe the client’s eyes for the six cardinal position of gaze
* Verify the client’s ability to read letters on a snellen eye chart
* Check the client’s pupil reaction when focusing on distant and nearby objects *
* Test the client’s eyes for reactions to light response

Answer 70

• Check the client’s pupil reaction when focusing on distant and nearby objects *

Question 71

1 .A nurse is teaching the assistive personnel about upper body mechanics to prevent injury. Which of
the following actions by the AP demonstrate an understanding of the teaching?

Answer 71

holding the object close to body

Question 72

A nurse is assessing a client who is immobile and notices a red area over the client’s coccyx. Which of
the following actions should the nurse take?
* Change the clients position every 4 hours
* Apply petroleum base ointment in the red area
* Assess the red area for blanching
* Use friction when cleansing the client’s skin

Answer 72

• Assess the red area for blanching

Question 73

73.. A nurse is planning care to prevent skin breakdown for a client who is immobile and has urinary
incontinence. Which of the following actions should the nurse include in the plan of care.

Answer 73

request a prescription for an indwelling urinary catheter

Question 74

A nurse is teaching a client who had an enucleation about care of an artificial eye. Which of the
following information should be included in the teaching? (select all that apply)
Store the artificial eye in the label container filled with 0.9% sodium chloride irrigation
Remove from the artificial eye by retracting the upper eyelid
Apply pressure just below artificial eye to break the suction
Clear the artificial eye with hydrogen peroxide before storing
Retract the upper and lower lids to reinsert the artificial eye

Answer 74

Apply pressure just below artificial eye to break the suction
Clear the artificial eye with hydrogen peroxide before storing
Retract the upper and lower lids to reinsert the artificial eye

Question 75

A nurse is caring for a client who is 2 days postoperative following bowel resection and reports
sudden severe abdominal pain. Which of the following actions should the nurse take first?
* Determine areas of resonance across the abdomen using a systematic approach
* Expose the client’s abdomen to look for changes in appearance
* Perform abdominal palpation by pressing gently with the finger pads
* Use the diaphragm of the stethoscope to listen for bowel sounds

Answer 75

• Expose the client’s abdomen to look for changes in appearance

Question 76

A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following
interventions is the nurses priority?
* Determine the client’s reading ability
* Review the use of an artificial larynx
* With the client schedule a support session
* For the client explain the techniques of esophageal speech

Answer 76

• For the client explain the techniques of esophageal speech

Question 77

A home care nurse is teaching a client about home safety. Which of the following statements by the
client indicates an understanding of the teaching? (select all that apply)
* I will use the bars when getting in and out of the bath tub
* I need to check my medications for expiration dates
* I need to have a fire escape plan with my family
* I will apply tape over frayed areas of electrical cords
* I need to set my hot water heater to 140 degrees Fahrenheit

Answer 77

I will use the bars when getting in and out of the bath tub
* I need to check my medications for expiration dates
* I need to have a fire escape plan with my family

Question 78

a nurse in an emergency department is assessing a client who reports a right lower quadrant pain,
nausea and vomiting for the past 48 hours? Which of the following actions should the nurse take
first?
o Offer pain medication
o Palpate the abdomen
o Auscultate bowel sounds

Answer 78

o Auscultate bowel sounds

Question 79

. A nurse is caring for a client who recently received a diagnosis of terminal cancer. Which of the
following statement by the client partner indicates maladaptive coping?

Answer 79

: I don’t know of if I will be able to meet his physical needs

Question 80

A nurse is planning care for a client who has a stage 1 pressure ulcer on the right heel. The nurse
should anticipate application of which of the following dressings?
o Dry gauge
o Transparent
o Calcium alginate
o Hydrogel

Answer 80

Transparent

Question 81

A nurse is caring for a client who has brain cancer and is transferring to hospice care. The client’s
son tells the nurse “I don’t know what to tell my dad if he asks how he is going to die”. Which of the following is an appropriate response from the nurse

Answer 81

“lets discuss your concerns about your father,” or anything along those lines that is
therapeutic.

Question 82

a nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for
corns and calluses toes. Which of the following statements by the client indicates understanding of
the teaching?
o I can apply lotion to soften the calluses as long as I don’t put lotion between my toes
o I can place an oval corn pad over toes that have corns as longs as a remove the pad
weekly
o I should soak my feet in warm water daily to soften corns and calluses
o I should use an over the counter liquid medication to remove corns

Answer 82

o I can apply lotion to soften the calluses as long as I don’t put lotion between my toes

Question 83

A nurse is caring for a client who has wrists restraints after an episode of violent behavior. Which of
the following actions should the nurse take?
* Tie the restraints to the side rail
* Secure restraints with a square knot
Remove one restraint at a time
* Remove the restraints every 3 hours

Answer 83

Remove one restraint at a time

Question 84

A nurse is admitting a client who has a clostridium difficile infection. Which of the following actions
should the nurse take? Select all that apply
Use an N95 respirator while providing client care
o Wear a gown and gloves when providing client care
o Assign the client to a private room with positive air flow
o Wash hands with soap and water after contact with the client
o Ensure the client does not receive fresh fruits

Answer 84

Wear a gown and gloves when providing client care
o Assign the client to a private room with positive air flow
o Wash hands with soap and water after contact with the client

Question 85

A nurse is planning care for a client who has latex allergy and is scheduled for surgery. Which of the
following actions is appropriate to include in the clients plan of care?
* Schedule the client as the first surgical procedure of the day
* Cleanse the stoppers with primidone iodine for withdrawing medication
* Remove the stop stocks from iv tubing
* Ensure the gloves in the surgical suite are powdered gloves

Answer 85

Schedule the client as the first surgical procedure of the da

Question 86

A nurse is providing discharge teaching to a client who does not speak the same language as the
nurse. Which of the following action should the nurse take

Answer 86

Direct verbal discharge instruction to the interpreter.

Question 87

A nurse is teaching a client how to self-administer daily low dose heparin injections. Which of the
following factors is most likely to increase the clients motivation to learn?
o The client’s belief that his needs will be met through education
o The nurse explaining the need for education to the client
o The client seeking family approval by agreeing to a teaching plan
The nurse’s empathy about the client having to self-inject

Answer 87

o The client’s belief that his needs will be met through education

Question 88

A nurse is caring for a client who is receiving continuous enteral feedings through gastrostomy
tubes. Which of the following actions should the nurse take?
Heat the formula to 105 degrees Fahrenheit
Flush the tubing with 10 ml of water every 2 hours
Change the tubing every 72 hours
Aspirate residual volume every 4 hours

Answer 88

Aspirate residual volume every 4 hours (Every 4-8 hours is correct)

Question 89

9. A nurse is caring for a client who has an incisional wound and a prescription for wound care. Which
   of the following answers indicates the proper method of cleaning a wound site?

Answer 89

“use a different sterile swab for each stroke.

Question 90

A nurse is teaching a client who requires maximum support about how to use a two wheeled walker.
Which of the following actions by the client indicates an understanding of teaching?
o The client picks up the walker with each step
o The client stoops slightly forward when moving the walker
o The client stands with her elbows slightly flexed while holding the walker
o The client moves the walker ahead 10 inches with each step

Answer 90

o The client stands with her elbows slightly flexed while holding the walker

Question 91

A nurse is caring for a client who refuses to follow the providers prescription for bed rest. The nurse
over hears the assistive personnel tell the client that if she does not remain in bed he will place her in
restraints. The nurse should identify that the AP is committing which of the following torts?
o Libel
o Defamation of character
o Assault
o Battery

Answer 91

Assault

Question 92

. A nurse is preparing to insert an IV catheter for an older adult client who has fragile skin. Which of
the following actions should the nurse take?
Stabilize the vein by applying traction above the insertion site
Engorge the vein by placing the arm in the dependent position
Use friction at the insertion site to increase venous distention
Leave the tourniquet on for 30 to 60 seconds after initial insertion

Answer 92

Engorge the vein by placing the arm in the dependent position

Question 93

A nurse is planning care for a client who has a new prescription for parental nutrition in 20%
dextrose and fat emulsion. Which of the following is the appropriate action to indicate in the plan of
care?
o Prepare the client for a central venous line
o Change the PN infusion bag every 48 hours
o Administer the PN and fat emulsion separately
o Obtain a random blood glucose daily

Answer 93

o Prepare the client for a central venous line

Question 94

A nurse is caring for a client who is schedule for surgery while witnessing the client signature. While
the client is saying I trust my doctor, but I don’t understand what he meant when he said he’ll reset my
intestines. Which of the following actions should the nurse take?
o Provide brochures about the procedure
o Notify the provider
o Complete an incident report
Describe the surgery to the client

Answer 94

o Notify the provider

Question 95

A nurse is caring for a client who is agitated and threating to harm others. The nurse places the
client in restraints but does not notify the provider or obtain a prescription for the restraints. The
situation respects which of the following torts?
o False imprisonment
o Invasion of privacy
o Assault
o Negligence

Answer 95

o False imprisonment

Question 96

. A nurse is conducting a Webber test on a client. Which of the following is an appropriate action for
the nurse to take?

Answer 96

; Place an activated tuning fork in the middle of the client’s forehead (should just be head not
forehead technically)

Question 97

A nurse on a medical unit is caring for a group of clients. For which of the following tasks should the
nurse wear a face shield.

Answer 97

Ans: Changing the brief of an older client who has Clostridium difficile

Question 98

An adult client tells a nurse about recent lack of sleep due to changing to a night shift job. Which of
the following interventions should the nurse suggest?
 Use the television to mask external noises
o Listen to soft music before lying down
o Exercise just prior to bedtime
 Keep the sleeping environment warm

Answer 98

o Listen to soft music before lying down

Question 99

A nurse is caring for a client who has a new diagnosis of fibromyalgia. The client tells the nurse that
she wants to use traditional Chinese medicine for treatment instead of the medication prescribed by her
provider. Which of the following is an appropriate response by the nurse?

Answer 99

Ans: You should ask the provider if she recommend traditional Chinese medicine.

Question 100

A nurse is caring for a client who reports that she has insomnia. Which of the following
interventions is appropriate for the nurse to recommend?
o Eat a light carbohydrate snack before bedtime
o Exercise 1 hour before bedtime
Drink a cup of hot cocoa before bedtime
o Take a 30 min nap daily

Answer 100

o Eat a light carbohydrate snack before bedtime