ATI Practice Tests (A/B) Flashcards
1
Q
A nurse is evaluating a client’s use of a cane. What action should the nurse identify as an indication of correct use?
A. The top of the cane is parallel to the clients waist.
B. When walking, the client moves the cane 46 cm (18in) forward.
C. The client holds the cane on the stronger side of her body.
D. The client moves her strong limb forward with the cane.
A
C. The client holds the cane on the stronger side of her body.
2
Q
A nurse received report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hr. What action should the nurse take first.
A. Reposition the client.
B. Document the clients IV intake in the medical record.
C. Request the new IV fluid prescription.
D. Check the IV tubing for obstruction.
A
D. Check the IV tubing for obstruction.
3
Q
A nurse is caring for a client who requires an NG tubes for stomach decompression. What action should the nurse take when inserting the NG tube?
A. Position the client with the head of the bed elevated to 30’ prior to insertion of the NG tube.
B. Remove the NG tube if the client begins to gage or choke.
C. Apply suction to the NG tube prior to insertion.
D. Have the client take sips of water to promote insertion of the NG tube into the esophagus.
A
D. Have the client take sips of water to promote insertion of the NG tube into the esophagus.
4
Q
A nurse is reviewing a clients fluid and electrolyte status. What finding should the nurse report to the provider? A. BUN 15 mg/dL B. Creatinine 0.8 mg/dL C. Sodium 143 mEq/L D. Potassium 5.4 mEq/L
A
D. Potassium 5.4 mEq/L
5
Q
A nurse is providing discharge instruction to a client who will be using a walker. What client statement indicates understanding of the teaching?
A. I can place an extension cord across my living room to plug in my television.
B. I will hire someone to trim the tree that hangs low over the stairs of my front porch.
C. I will place my alarm clock on my bedroom dresser across the room.
D. I will replace the old throw rug in my kitchen with the new one.
A
B. I will hire someone to trim the tree that hangs low over the stairs of my front porch.
6
Q
A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. What tasks should the nurse assign to an AP? (SATA)
A. Assist the client with a partial bed bath.
B. Measure the clients BP after the nurse administers an antihypertensive medication.
C. Test the clients swallowing ability by providing thickened liquids.
D. Use a communication board to ask what the client wants for lunch.
E. Irrigate the clients indwelling urinary catheter.
A
A, B, & D
7
Q
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. What actions should the nurse take?
A. Discuss the risk factors for colon cancer.
B. Focus teaching on what the client will need to do in the future to manage his illness.
C. Provide the client with written information about the phases of loss and grief.
D. Reassure the client that this is an expected response to grief.
A
D. Reassure the client that this is an expected response to grief.
8
Q
A nurse is preparing to apply a dressing for a client who has stage 2 pressure injury. What type of dressing should the nurse use? A. Alginate B. Gauze C. Transparent D. Hydrocolloid
A
D. Hydrocolloid (promote healing in stage 2 pressure injuries by creating a moist wound bed)
9
Q
A nurse is administering an otic medication to an older adult client. What action should the nurse take to ensure that the medication reaches the inner ear?
A. Press gently on the tragus of the clients ear
B. Pack a small piece of cotton deep into the clients ear canal
C. Move the clients auricle down and back toward her head
D. Tilt the clients head backward for 5 min
A
A. Press gently on the tragus of the clients ear.
10
Q
A nurse is using an open irrigation technique to irrigate a clients indwelling urinary catheter. What action should the nurse take?
A. Place the client in a side-lying position.
B. Instill 15 mL of irrigation fluid into the catheter with each flush.
C. Subtract the amount of irrigant used from the clients urine output.
D. perform the irrigation suing a 20-mL syringe.
A
C. Subtract the amount of irritant used from the clients urine output.
11
Q
A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. What precaution should the nurse plan for this client?
A. Make sure the clients room has at least six air exchanges per hour.
B. Make sure the client wears a mask when outside her room if there is construction in the area.
C. Place the client in a private room with negative-pressure airflow.
D. Wear an N95 respirator when giving the client direct care.
A
B. Make sure the client wears a mask when outside her room if there is construction in the area
12
Q
A nurse is planning strategies to manage time effectively for client care. What strategy should the nurse implement?
A. Combine client care tasks when caring for multiple clients
B. Wait until the end of the shift to document client care
C. Use the planning step of the nursing process to prioritize client care delivery.
D. Allow for interruption in tasks to discuss client care issues with colleagues.
A
C. Use the planning step of the nursing process to prioritize client care delivery.
13
Q
A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. What action should the nurse take?
A. Assist the client into a prone position.
B. Place a sleeve over the top of each leg with the opening at the knee.
C. Make sure two fingers can fit under the sleeves.
D. Set the ankle pressure at 65 mm Hg.
A
C. Make sure two fingers can fit under the sleeves.
14
Q
A nurse is caring for a client who has a respiratory infection. What technique should the nurse use when performing nasotracheal suctioning for the client?
A. Insert the suction catheter while the client is swallowing.
B. Apply intermittent suction when withdrawing the catheter.
C. Place the catheter in a location that is clean and dry for later use.
D. Hold the suction catheter with her clean, non dominant hand.
A
B. Apply intermittent suction when withdrawing the catheter.
15
Q
A nurse is assessing a client who reports increased pain following physical therapy. What question should the nurse ask when assessing the quality of the clients pain?
A. Is your pain constant or intermittent?
B. What would you rate your pain on a scale of 0 to 10?
C. Does the pain radiate?
D. Is your pain sharp or dull?
A
D. Is your pain sharp or dull?
16
Q
A nurse is providing discharge teaching to a client about self-administering heparin. What instruction should the nurse include in the teaching?
A. Insert the needle at a 15’ angle.
B. Aspirate for blood return prior to administration.
C. Administer the medication into the abdomen.
D. Massage the site following the injection.
A
C. Administer the medication into the abdomen.
17
Q
A nurse is teaching a client and his family how to care for the clients tracheostomy at home. What instructions should the nurse include in the teaching?
A. Remove the outer cannula cautiously for routine cleaning.
B. Use tracheostomy covers when outdoors.
C. Use sterile technique when performing tracheostomy care at home.
D. Cleanse irritated skin with full-strength hydrogen peroxide.
A
B. Use tracheostomy covers when outdoors.
18
Q
A nurse is caring for a client who has a terminal illness and is approaching death. The client is SOB and has noisy respirations from secretions in their airway. What action should the nurse take? A. Turn the client every 2 hrs. B. Administer an antiemetic every 6 hrs. C. Hold oral care. D. Increase the room's temperature.
A
A. Turn the client every 2 hrs.
19
Q
A nurse is caring for a child who has a prescription for a blood transfusion. The child’s parents have refused the treatment due to their religious beliefs. What actions should the nurse take?
A
Examine personal values about the issue.
20
Q
A nurse is preparing to administer enoxparin subcutaneously to a client. What action should the nurse take?
A. Administer the medication with the needle at a 45’ angle.
B. Administer the medication into the client’s non dominant arm.
C. Pull the clients skin laterally or downward prior to administration.
D. Massage the injection site after administration.
A
A. Administer the medication with the needle at a 45’ angle.
21
Q
A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client’s care. when should the nurse initiate discharge planning?
A. During the admission process
B. As soon as the clients condition is stable
C. During the initial team conference
D. After consulting with the clients family
A
A. During the admission process
22
Q
A nurse is assessing a client who has required bed rest for the past month. What finding should the nurse identify as an indication that the client has developed thrombophlebitis? A. Bladder distention B. Decreased blood pressure C. Calf swelling D. Diminished bowel sounds
A
C. Calf swelling
23
Q
A nurse is caring for a client who has dementia. What intervention should the nurse take to minimize the risk for injury to the client?
A. Use a bed exit alarm system
B. Raise four side rails while the client is in bed
C. Apply one soft wrist restraint
D. Dim the lights in the clients room
A
A. Use a bed exit alarm system
24
Q
A nurse is assessing an older adult clients risk for falls. Which of the following assessments should the nurse use to identify the clients safety needs? (SATA) A. Lacrimal apparatus B. Pupil clarity C. Appearance of bulbar conjunctivae D. Visual fields E. Visual acuity
A
B, D, & E
25
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A nurse is caring for a client who has pharyngeal diphtheria. What type of transmission precaution should the nurse initiate?
A. Contact
B. Droplet
C. Airborne
D. Protective
```
B. Droplet
26
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A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary alternative therapies for pain control. The nurse should inform the client that this condition is contraindicated for what therapy?
A. Biofeedback
B. Aloe
C. Feverfew
D. Acupuncture
```
D. Acupuncture
27
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A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. What types of transmission precautions should the nurse initiate?
A. Protective environment
B. Airborne
C. Droplet
D. Contact
```
D. Contact precautions
28
A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the ED and I had difficulty breathing?" What response should the nurse make?
We would give you oxygen through a tube in your nose.
29
A nurse is performing a skin assessment for a client who expresses concerns about skin cancer. What finding should the nurse identify as a potential indication of a skin malignancy?
A. A lesion with uniform pigmentation
B. New appearance of petechiae
C. A mole with an asymmetrical appearance
D. The presence of papule
C. A mole with an asymmetrical appearance
30
A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. What action should the nurse include?
A. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter.
B. Regulate oxygen via nasal cannulate at a flow rate of no more than 6 L/min.
C. Make sure the reservoir bag of a partial rebreathing mask remains deflated.
D. Use petroleum jelly to lubricate a clients nares, face, and lips.
B. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min.
31
A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. What observation should the nurse identify as properly safety protocol?
A. The client uses a wool blanket on their bed.
B. The client identifies the location of a fire extinguisher.
C. The client stores an extra oxygen tank on its side under their bed.
D. The client has a weekly inspection checklist for oxygen equipment.
B. The client identifies the location of a fire extinguisher.
32
A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize that what statement by the clients partner indicates effective coping?
A. I am not worried because I still have hope that he will be okay.
B. I am relying on support from our family during this time.
C. We can plan our family reunion once he recovers and comes home.
D. We don't see any reason to start discussing funeral arrangements right now.
B. I am relying on support from our family during this time.
33
A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." What response should the nurse make?
"Lets talk about how the change in your job status will affect you."
34
A nurse is caring for a group of clients. What actions should the nurse take to prevent the spread of infection?
A. Carry a clients soiled linens out of the room in a mesh linen bag.
B. Place the client who has TB in a room with negative-pressure airflow.
C. Provide disposable plates and utensils for a client who is HIV-positive.
D. Dispose of a client's blood-matured dressing in a trash bag inside a second trash bag.
B. Place a client who has TB in a room with negative-pressure airflow.
35
A nurse is admitting a new client. What action should the nurse take while performing medication reconciliation?
Compare the clients home medications with the providers prescriptions.
36
A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should he nurse take when lifting this object?
A. Bend at the waist.
B. Keep his feet close together.
C. Use his back muscles for lifting.
D. Stand close to the cabinet when lifting it.
D. Stand close to the cabinet when lifting it.
37
A nurse is caring for a client who is post-op and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the clients vital signs every 15 min and report back in 1 hr. What action should the nurse take next?
A. Document the providers statement in the medical record.
B. Complete an incident report.
C. Consult the facility's risk manager.
D. Notify the nursing manager.
D. Notify the nursing manager.
38
A nurse is talking with the partner of a client who has dementia. The clients partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify the partner is experiencing what type of role-performance stresses?
Role overload
39
A nurse is preparing a change-of-shift. What tools or documents should the nurse use to communicate continuity of care?
A. Critical pathway
B. Situation, background, assessment, and recommendation (SBAR)
C. Transfer report
D. Medication administration record (MAR)
B. SBAR
40
A nurse is planning to insert a peripheral IV catheter for an older adult client. What actions should the Nurs plan to take?
A. Insert the catheter at a 45' angle.
B. Place the clients arm in a dependent position.
C. Shave excess hair from the insertion site.
D. Initiate IV therapy in the veins of the hand.
B. Place the clients arm in a dependent position.
41
A nurse is caring for a client who is post-op and refuses to use an incentive spirometer following major abdominal surgery. What action should the nurse prioritize?
Determine the reasons why the client is refusing to use the incentive spirometer.
42
A nurse is preparing to review medication documentation with a group of newly licensed nurses. What statement should the nurse manager plan to include in the teaching?
A. Use the complete name of the medication magnesium sulfate.
B. Delete the space between the numerical dose and the unit of measure.
C. Write the letter U when noting the dosage of insulin.
D. Use the abbreviation SC when indicating an injection.
A. Use the complete name of the medication magnesium sulfate.
43
A nurse is responding to a call light and finds a client lying on the bathroom floor. What action should the nurse take first?
A. Check the client for injuries.
B. Move hazardous objects away from the client.
C. Notify the provider.
D. Ask the client to describe how she felt prior to the fall.
A. Check the client for injuries
44
A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. What action should the nurse take?
A. Pad the clients wrist before applying the restraints.
B. Evaluate the clients circulation every 8 hr after application.
C. Remove the restraints every 4 hr to evaluate the clients status.
D. Secure the restraint ties to the bed's side rails.
A. Pad the clients wrist before applying the restraints.
45
A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. What finding should the nurse identify as a possible cause of the diarrhea.
The client's caregiver washes out the feeding bag with warm water once every 24 hr.
46
A nurse is caring for a client who is post-op. When the nurse prepares to change her dressing, she says, "Every time you change my bandage, it hurts so much." What intervention should the nurse prioritize?
A. Encourage the client to relax and take deep breaths during the dressing change.
B. Educate the client about the importance of the dressing change to prevent infection.
C. Assist the client to a comfortable position for the dressing change.
D. Administer pain medication 45 min before changing the client's dressing.
D. Administer pain medication 45 min before changing the clients dressing.
47
A nurse is caring for a client who has diarrhea due to shigella. What precaution should the nurse implement for this client?
A. Have the client wear a mask when receiving visitors.
B. Limit the clients time with visitors to no more than 30 min a day.
C. Assign the client to a room with negative-pressure airflow exchange.
D. Wear a gown when caring for the client
D. Wear a gown when caring for the client.
48
```
A nurse is administering 1 L of 0.9% sodium chloride to a client who is post-op and has fluid volume deficit. What changes should the nurse identify as an indication that the treatment was successful?
A. Increase in hematocrit
B. Increase in respiratory rate
C. Decrease in heart rate
D. Decrease in capillary refill time
```
C. Decrease in heart rate.
49
A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. What action should the nurse take?
A. Ask another nurse to observe the medication wastage.
B. Notify the pharmacy when wasting the medication.
C. Lock the remaining medication in the controlled substances cabinet.
D. Dispose of the vial with the remaining medication in a sharps container.
A. Ask another nurse to observe the medication wastage.
50
```
A nurse is caring for a client who has a sodium level of 125 mEq/L. What finding should the nurse expect?
A. Numbness of the extremities
B. Bradycardia
C. Positive Chvostek's sign
D. Abdominal cramping
```
D. Abdominal cramping
51
A nurse is preparing an education program for staff about advocacy. What information should the nurse include?
A. Advocacy ensures clients safety, heath, and rights.
B. Advocacy ensures that nurses are able to explain their own actions.
C. Advocacy ensures that nurses follow through on their promises to clients.
D. Advocacy ensures fairness in client care delivery and use of resources.
A. Advocacy ensures clients safety, health, and rights.
52
A nurse is assessing a client's readiness to learn about insulin self-administration. What statement should the nurse identify as an indication that the client is ready to learn?
A. I can concentrate best in the morning.
B. It is difficult to read the instructions because my glasses are at home.
C. Im wondering why I need to learn this.
D. You will have to talk to my wife about this.
A. I can concentrate best in the morning.
53
A nurse is caring for a client who asks about the purpose of advance directives. What statement should the nurse make?
A. They allow the court to overrule an adult clients refusal of medical treatment.
B. They indicate the form of treatment a client is willing to accept in the event of a serious illness.
C. They permit a client to withhold medical information from health care personnel.
D. They allow health care personnel in the emergency department to stabilize a clients condition.
B. They indicate the form of treatment a client is willing to accept in the event of a serious illness.
54
A nurse is assessing four adult clients. What physical assessment technique should the nurse use?
Ensure the bladder of the blood pressure cuff surrounds 80% of the clients arm.
55
A client who is post-op is verbalizing pain as a 2 on a pain scale of 0 to 10. What statement should the nurse identify as an indication that the client understands the post-op teaching she received about pain management?
It might help me to listen to music while I'm lying in bed.
56
A charge nurse is discussing the responsibility of nurses caring for clients who have Clostridium difficile infection. What information should the nurse include in the teaching?
A. Assign the client to a room with a negative airflow system.
B. Use alcohol-based hand sanitizer when leaving the client's room.
C. Clean contaminated surfaces in the client's room with a phenol solution.
D. Have family members wear a gown and gloves when visiting.
D. Have family members wear a gown and gloves when visiting.
57
```
A nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. What piece of information is the priority for the nurse to provide?
A. Admitting diagnosis
B. Breath sounds
C. Body temperature
D. Diagnostic test results
```
B. Breath sounds
58
A nurse is preparing to delegate client care tasks to an assistive personnel (AP). What task should the nurse delegate?
A. Ambulating a client who is postoperative
B. Inserting an indwelling urinary catheter for a client.
C. Demonstrating the use of an incentive spirometer to a client
D. Confirming that a client's pain has decreased after receiving an analgesic
A. Ambulating a client who is postoperative
59
A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. What statement should the nurse document about this incident?
A. "Incident report completed."
B. "Client climbed over the side rails."
C. "Client found lying on floor."
D. "Client was trying to get out of bed."
C. "Client found lying on floor."
60
A nurse is caring for a client who has a prescription for wound irrigation. What action should the nurse take?
A. Wear sterile gloves when removing the old dressing.
B. Warm the irrigation solution to 40.5'C (105'F).
C. Cleanse the wound from the center outward.
D. Use a 20-mL syringe to irrigate the wound.
C. Cleanse the wound from the center outward.
61
```
A nurse is admitting a client who has rubella. What types of transmission-based precautions should the nurse initiate?
A. Droplet
B. Airborne
C. Contact
D. Protective environment
```
A. Droplet
62
A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. What instructions should the nurse provide the client and his family? (SATA)
A. Check the cord routinely for frays or tearing.
B. Keep the unit at least 1.2 m (4 ft) away from a gas stove.
C. Consider purchasing a generator for power backup.
D. Observe for signs of hypoxia.
E. Select synthetic clothing and bedding.
A, C, & D
63
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A nurse is calculating a client's fluid intake over the past 8 hr. What items should the nurse plan to document on the clients intake and output record as 12mL of fluid?
A. 2 cups of soup
B. 1 quart of water
C. 8 oz of ice chips
D. 6 oz of tea
```
C. 8 oz of ice chips (4 oz of liquid water is equal to 12 mL of fluid)
64
A nurse is caring for a client who has tuberculosis. What actions should the nurse take? (SATA)
A. Place the client in a room with negative-pressure airflow.
B. Wear gloves when assisting the client with oral care.
C. Limit each visitor to 2-hr increments.
D. Wear a surgical mask when providing client care.
E. Use antimicrobial sanitizer for hand hygiene.
A, B, & E
65
A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The clients partner wants the client to have the blood transfusion. What action should the nurse take?
A. Ask the client to consider a direct donation.
B. Withhold the blood transfusion.
C. Request a consultation with the ethics committee.
D. Ask the client's family to intervene.
B. Withhold the blood transfusion.
66
A nurse is teaching a client whose left leg is in a cast about using crutches. What statement should the nurse identify as an indication that the client understands the teaching?
A. "When descending stairs, I will first shift my weight to my right leg."
B. "I should place my crutches 12 inches in front and to the side of each foot."
C. "As I sit down, I will hold one crutch in each hand."
D. "I will make sure the shoulder rests are snug against my armpits."
A. When descending stairs, I will first shift my weight to my right leg.
67
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A nurse has accepted a verbal prescription "for three tenths of a milligram of levothyroxine IV stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the clients medical record?
A. .3 mg
B. 0.3 mg
C. 0.3. mg
D. 3/10 mg
```
B. 0.3 mg
68
```
A nurse is caring for a client who has an indwelling urinary catheter. What finding indicates that the catheter requires irrigation?
A. Urine has an unusual odor.
B. Urine specific gravity is 1.035.
C. Bladder scan shows 525 mL of urine.
D. Urine is positive for ketones.
```
C. Bladder scan shows 525 mL of urine.
69
```
A nurse is assessing an adult client who has been immobile for the past 3 weeks. What finding should the nurse intervene?
A. Erythema on pressure points.
B. Lower-extremity pulse strength of 2+
C. Fluid intake of 3,000 mL per day
D. One bowel movement every other day
```
A. Erythema on pressure points
70
A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. What action should the nurse take first?
A. Rinse the feeding bag with water between feedings.
B. Tell the client to keep the head of the bed elevated at least 30'.
C. Make sure the enteral formula is at room temperature.
D. Wipe the top of the formula can with alcohol.
B. Tell the client to keep the head of the bed elevated at least 30'.
71
A nurse on a medical unit is preparing to discharge a client home. What action should the nurse take as part of the medication reconciliation process?
A. Seal unused medications from the facility in a plastic bag.
B. Evaluate the clients ability to self-administer medications.
C. Report an identified discrepancy to The Joint Commission.
D. Compare prescriptions with medications the client received while at the facility.
D. Compare prescriptions with medications the client received while at the facility.
72
A nurse is caring for a client who requires a 24-hr urine collection. What statements by the client indicates an understanding of the teaching?
A. "I had a bowel movement, but I was able to save the urine."
B. "I have a specimen in the bathroom from about 30 minutes ago."
C. "I flushed what I urinated at 7:00am and have saved all urine since."
D. "I drink a lot, so I will fill up the bottle and complete the test quickly."
C. I flushed what I urinated at 7am and have saved all urine since. (client should discard first voiding and save all subsequent voidings.)
73
A nurse is planning an educational program for a group of older adults at a senior living center. What recommendations should the nurse include?
A. You should have an eye examination every 2 years.
B. You should receive a tenants booster every 5 years.
C. You should receive a shingles vaccine when you are 70 years old.
D. You should receive a pneumococcal vaccine when you are 65 years old.
D. You should receive a pneumococcal vaccine when you are 65 years old.
74
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A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. What finding should the nurse expect?
A. Neck vein distention
B. Urine specific gravity 1.010
C. Rapid heart rate
D. Blood pressure 144/82 mm/Hg
```
C. Rapid heart rate
75
A nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia (PCA) pump. What action should the nurse take?
A. Instruct the family to refrain from pushing the button for the client while she is asleep.
B. Inform the client that because she is on PCA, vital signs will be taken every 8 hr.
C. Teach the client to avoid pushing the button until pain is above a 7 on a scale of 0-10.
D. Increase the basal rate and shorten the lock-out interval time if the clients pain level is too high.
A. Instruct the clients family to refrain rom pushing the button for the client while she is asleep.
76
A community health nurse is checking BP for a group of clients at a community health screening. What client is at an increased risk for hypertension?
A. A client who is 52 years old
B. A client who smokes one pack of cigarettes each day
C. A client who walks for 30 min every day
D. A client who drinks one glass of wine three times per week
B. A client who smokes one pack of cigarettes each day
77
A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" What response should the nurse make?
A. Ill get a blood sample from you and send it for a screening test.
B. Beginning at age 60, you should have a colonoscopy.
C. You should have a fecal occult blood test every year.
D. The recommendation is to have a sigmoidoscopy every 10 years.
C. You should have a fecal occult b blood test every year.
78
A nurse is reviewing practice guidelines with a group of newly licensed nurses. What interventions should the nurse include that is within the RN scope?
A. Insert an implanted port.
B. Close a laceration with sutures.
C. Place an endotracheal tube.
D. Initiate an enteral feeding through a gastronomy tube.
D. Initiate an enteral feeding through a gastrostomy tube.
79
A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. What statement should the nurse identify as an indication that the client understands the use of this assistive device?
A. This type of hearing aid does not allow for fine tuning of volume.
B. I shouldn't have trouble keeping the hearing aid in place during exercise.
C. I expect to hear a whistling sound when I first insert the hearing aid.
D. I will be sure to remove my hearing aid before taking a shower.
D. I will be sure to remove my hearing aid before taking a shower.
80
A nurse is caring for a client who has decreased mobility. What action should the nurse take to decrease the clients risk of developing plantar flexion contractures?
A. Place a pillow under the clients knees.
B. Position a trochanter roll under each of the clients hips.
C. Advise the client to wear rubber-soled slippers.
D. Apply an ankle-foot orthotic device to the clients feet.
D. Apply an ankle-foot orthotic device to the clients feet.
81
A nurse in a surgical suite notes documentation on a clients medical record that he has a latex allergy. In preparation for the clients procedure, what precautions should the nurse take?
A. Ensure sterilization of non disposable items with ethylene oxide.
B. Wrap monitoring cords with stockinette and tape them in place.
C. Cleanse latex ports on IV tubing with chlorhexidine before injecting medications.
D. Wear hypoallergenic latex gloves that contain powder.
B. Wrap monitoring cords with stockinette and tape them in place.
82
A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. What finding should the nurse identify as a potential indication of elder abuse?
The caregiver insists on remaining in the room.
83
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A nurse is administering IV fluids to a client. When monitoring for adverse effects, what assessments should the nurse identify as the priority?
A. Auscultate lung sounds.
B. Measure urine output.
C. Monitor BP readings.
D. Monitor electrolyte levels.
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A. Auscultate lung sounds.
84
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A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. What types of activity should the nurse recommend?
A. Walking briskly
B. Riding a bicycle
C. Performing isometric exercises
D. Engaging in high-impact aerobics
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A. Walking briskly
85
A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. What response should the nurse make?
We can talk about advance directives, and I can also give you some brochures about them.
86
A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients?
A. A client who has a history of physical abuse.
B. A client who has a permanent pacemaker.
C. A client who has ulcerative colitis
D. A client who has asthma
D. A client who has asthma
87
A nurse is discussing the use of herbal supplements for health promotion with a client. What client statement indicates an understanding of herbal supplement use?
A. I can take echinacea to improve my immune system
B. I can take feverfew to reduce my level of anxiety.
C. I can take ginger to improve my memory.
D. I can take ginkgo blob to relieve nausea
A. I can take echinacea to improve my immune system.
88
A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. What actions should the nurse take?
A. Gently shake the container of medication prior to administration.
B. Transfer the medication to a medicine cup.
C. Place the client in a semi-Fowler's position prior to medication administration.
D. Verify the dosage by measuring the liquid before administering it.
A. Gently shake the container of the medication prior to administration.
89
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A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. What methods should the nurse use as a psychomotor approach to learning?
A. Role play
B. Group discussions
C. Question-answer meetings
D. Practice sessions
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D. Practice sessions
90
A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. What actions should the nurse plan to take?
A. Use a resuscitation bag with 80% oxygen prior to the procedure.
B. Select a suction catheter that is half the size of the lumen.
C. Place the end of the suction catheter in water-soluble lubricant.
D. Adjust the wall suction apparatus to pressure of 170 mm Hg.
B. Select a suction catheter that is half the size of the lumen.
91
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A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. What documentation should the nurse include?
A. Client flow sheet
B. Acuity ratings
C. Current medications
D. Incident reports
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C. Current medications
92
A nurse has just inserted an NG tube for a client. What finding should the nurse expect to confirm correct tube placement?
A. The tube aspirate has a pH of 7.
B. An x-ray shows the end of the tube above the pylorus.
C. Bowel sounds are present on auscultation.
D. The client reports relief of nausea.
B. An x-ray shows the end of the tube above the pylorus.
93
A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. What action by the newly licensed nurse requires intervention by the charge nurse?
A. The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field.
B. The newly licensed nurse places sterile objects 2.5 cm (1 in) within the border of the field.
C. The newly licensed nurse holds the bottle of sterile saline outside the edge of the field when pouring.
D. The sterile field is positioned at the level of the newly licensed nurse's waist.
A. The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field.
94
A nurse manager is overseeing the care activities on a unit. What situation should the nurse manage intervene due to a violation of HIPAA guidelines?
A. A nurse who is caring for a client reviews the clients medical chart with a nursing student who is working with the nurse.
B. A nurse asks a nurse from another unit to assist with documentation for a client.
C. A nurse who is caring for a client returns a call to the person appointed in the health care proxy to discuss the clients care.
D. A nurse discusses a clients status with the physical therapist who is caring for the client.
B. A nurse asks a nurse from another unit to assist with documentation for a client.
95
A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." What response should the nurse make?
A. Most people are happy when their children grow up and leave home.
B. You should be proud that your children are becoming independent.
C. Maybe you should consider why you are feeling useless.
D. People in middle adulthood often find satisfaction in nurturing and guiding young people.
D. People in middle adulthood often find satisfaction in nurturing and guiding young people.
96
A nurse is planning care for a client who has vision loss. What interventions should the nurse include in the plan of care to assist the client with feeding?
A. Assign a staff member to feed the client.
B. Provide small-handled utensils for the client.
C. Thicken liquids on the clients tray.
D. Arrange food in a consistent pattern on the clients plate.
D. Arrange food in a consistent pattern on the clients plate.
97
A nurse is caring for a client who requires an informed consent for a surgical procedure. What action is the nurses responsibility?
A. Describe the procedure to the client.
B. Witness the clients signature on the consent form.
C. Inform the client of alternatives to the procedure.
D. Tell the client which team members will assist with the procedure.
B. Witness the clients signature on the consent form.
98
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A nurse is planning care for a client who has tuberculosis. The nurse should use what piece of personal protective equipment when providing care for the client?
A. Gown
B. N95 respirator
C. Shoe covers
D. Surgical cap
```
B. N95 respirator
99
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A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. What finding at the IV site should the nurse identify as indicating infiltration?
A. Purulent exudate
B. Warmth
C. Skin blanching
D. Bleeding
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C. Skin blanching
100
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A client who is non ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, what action should the nurse take next?
A. Activate the emergency fire alarm.
B. Extinguish the fire.
C. Evacuate the client.
D. Confine the fire.
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C. Evacuate the client.
101
A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, what action should the nurse take next?
A. Rock the client up to a standing position.
B. Pivot on the foot that is the farthest form the chair.
C. Assess the client for orthostatic hypotension.
D. Apply a gait belt to the client.
C. Assess the client for orthostatic hypotension.
102
A nurse is caring for a client who reports pain. When documenting the quality of the clients pain on an initial pain assessment, the nurse should record what client statement?
A. Im having mild pain.
B. The pain is like a dull ache in my stomach.
C. I notice that the pain gets worse after I eat.
D. The pain makes me feel nauseous.
B. The pain is like a dull ache in my stomach.
103
A nurse is performing a Romberg test during the physical assessment of a client. What technique should the nurse use?
A. Touch the face with a cotton ball.
B. Apply a vibrating tuning fork to the clients forehead.
C. Have the client stand with their arms at their sides and their feet together.
D. Perform direct percussion over the area of the kidneys.
C. Have the client stand with their arms at their sides and their feet together.
104
A nurse is caring for a client who has terminal liver cancer. What statement should the nurse identify as an indication that the client is experiencing spiritual distress?
A. What could I have done to deserve this illness?
B. I blame medical science for not curing me.
C. Where is my daughter at a time like this?
D. Will I ever begin to feel in charge of my life again?
A. What could I have done to deserve this illness?
105
A nurse is admitting a client who has been having frequent tonic-clonic seizures. What action should the nurse add to the clients plan of care?
A. Wrap blankets around all four sides of the bed.
B. Apply restraints during seizure activity.
C. Place the client in a supine position during seizure activity.
D. Have a tongue depressor at the clients bedside.
A. Wrap blankets around all four sides of the bed.
106
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A nurse is reviewing a clients medication prescription that reads, "digoxin 0.25 by mouth every day." What component of the prescription should the nurse verify with the provider?
A. Medication name
B. Route of administration
C. Medication dose
D. Frequency of administration
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C. Medication dose
107
A nurse is caring for a group of clients on a medical-surgical unit. What situation does the nurse demonstrate the ethical principle of veracity?
A. A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively.
B. A client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the clients wishes.
C. A client who has a do-not-resuscitate (DNR) order has a cardiac arrest, and the nurse does not perform CPR despite requests from the clients family.
D. A client who is about to undergo a painful procedure receives pain medication 30 min before the procedure that the nurse previously promised to administer.
A. A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively.
108
A nurse is caring for a client who has limited mobility in his lower extremities. What action should the nurse take to prevent skin breakdown.
A. Place the client in high-Fowler's position.
B. Increase the clients intake of carbohydrates.
C. Massage reddened areas with unscented lotion.
D. Have the client use a trapeze bar when changing position.
D. Have the client use a trapeze bar when changing position.
109
A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. What action should the nurse plan to take?
A. Dissolve each medication in 5mL of sterile water.
B. Draw up medications together in the syringe.
C. Push the syringe plunger gently when feeling resistance.
D. Flush the tube with 15 mL of sterile water.
D. Flush the tube with 15 mL of sterile water. (Should flush feeding tube with 15-30 mL of sterile water before administration and between each medication. Flush feeding tube with 30-60mL of sterile water following administration of last medication)
110
A nurse is caring for a client who reports difficulty falling asleep. What recommendation should the nurse make?
A. Drink a cup of hot cocoa before bedtime.
B. Maintain a consistent time to wake up each day.
C. Exercise 1 hour before going to bed.
D. Watch a television program in bed before going to sleep.
B. Maintain a consistent time to wake up each day.
111
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A nurse is assessing a client who received an IV fluid bolus for dehydration. What finding should the nurse identify as an indication of fluid volume excess?
A. Hypotension
B. Weak, thready pulse
C. Slow capillary refill
D. Distended neck veins
```
D. Distended neck veins
