ATI Practice Tests (A/B)

Question 1

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.

Answer 1

C. The client holds the cane on the stronger side of her body.

Question 2

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.

Answer 2

D. Check the IV tubing for obstruction.

Question 3

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.

Answer 3

D. Have the client take sips of water to promote insertion of the NG tube into the esophagus.

Question 4

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

Answer 4

D. Potassium 5.4 mEq/L

Question 5

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.

Answer 5

B. I will hire someone to trim the tree that hangs low over the stairs of my front porch.

Question 6

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.

Answer 6

A, B, & D

Question 7

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.

Answer 7

D. Reassure the client that this is an expected response to grief.

Question 8

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

Answer 8

D. Hydrocolloid (promote healing in stage 2 pressure injuries by creating a moist wound bed)

Question 9

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

Answer 9

A. Press gently on the tragus of the clients ear.

Question 10

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.

Answer 10

C. Subtract the amount of irritant used from the clients urine output.

Question 11

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.

Answer 11

B. Make sure the client wears a mask when outside her room if there is construction in the area

Question 12

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.

Answer 12

C. Use the planning step of the nursing process to prioritize client care delivery.

Question 13

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.

Answer 13

C. Make sure two fingers can fit under the sleeves.

Question 14

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.

Answer 14

B. Apply intermittent suction when withdrawing the catheter.

Question 15

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?

Answer 15

D. Is your pain sharp or dull?

Question 16

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.

Answer 16

C. Administer the medication into the abdomen.

Question 17

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.

Answer 17

B. Use tracheostomy covers when outdoors.

Question 18

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.

Answer 18

A. Turn the client every 2 hrs.

Question 19

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?

Answer 19

Examine personal values about the issue.

Question 20

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.

Answer 20

A. Administer the medication with the needle at a 45’ angle.

Question 21

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

Answer 21

A. During the admission process

Question 22

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

Answer 22

C. Calf swelling

Question 23

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

Answer 23

A. Use a bed exit alarm system

Question 24

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

Answer 24

B, D, & E

Question 25

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

Answer 25

B. Droplet

Question 26

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

Answer 26

D. Acupuncture

Question 27

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

Answer 27

D. Contact precautions

Question 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?

Answer 28

We would give you oxygen through a tube in your nose.

Question 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

Answer 29

C. A mole with an asymmetrical appearance

Question 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.

Answer 30

B. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min.

Question 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.

Answer 31

B. The client identifies the location of a fire extinguisher.

Question 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.

Answer 32

B. I am relying on support from our family during this time.

Question 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?

Answer 33

“Lets talk about how the change in your job status will affect you.”

Question 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.

Answer 34

B. Place a client who has TB in a room with negative-pressure airflow.

Question 35

A nurse is admitting a new client. What action should the nurse take while performing medication reconciliation?

Answer 35

Compare the clients home medications with the providers prescriptions.

Question 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.

Answer 36

D. Stand close to the cabinet when lifting it.

Question 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.

Answer 37

D. Notify the nursing manager.

Question 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?

Answer 38

Role overload

Question 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)

Answer 39

B. SBAR

Question 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.

Answer 40

B. Place the clients arm in a dependent position.

Question 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?

Answer 41

Determine the reasons why the client is refusing to use the incentive spirometer.

Question 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.

Answer 42

A. Use the complete name of the medication magnesium sulfate.

Question 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.

Answer 43

A. Check the client for injuries

Question 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.

Answer 44

A. Pad the clients wrist before applying the restraints.

Question 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.

Answer 45

The client’s caregiver washes out the feeding bag with warm water once every 24 hr.

Question 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.

Answer 46

D. Administer pain medication 45 min before changing the clients dressing.

Question 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

Answer 47

D. Wear a gown when caring for the client.

Question 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

Answer 48

C. Decrease in heart rate.

Question 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.

Answer 49

A. Ask another nurse to observe the medication wastage.

Question 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

Answer 50

D. Abdominal cramping

Question 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.

Answer 51

A. Advocacy ensures clients safety, health, and rights.

Question 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.

Answer 52

A. I can concentrate best in the morning.

Question 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.

Answer 53

B. They indicate the form of treatment a client is willing to accept in the event of a serious illness.

Question 54

A nurse is assessing four adult clients. What physical assessment technique should the nurse use?

Answer 54

Ensure the bladder of the blood pressure cuff surrounds 80% of the clients arm.

Question 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?

Answer 55

It might help me to listen to music while I’m lying in bed.

Question 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.

Answer 56

D. Have family members wear a gown and gloves when visiting.

Question 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

Answer 57

B. Breath sounds

Question 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

Answer 58

A. Ambulating a client who is postoperative

Question 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.”

Answer 59

C. “Client found lying on floor.”

Question 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.

Answer 60

C. Cleanse the wound from the center outward.

Question 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

Answer 61

A. Droplet

Question 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.

Answer 62

A, C, & D

Question 63

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

Answer 63

C. 8 oz of ice chips (4 oz of liquid water is equal to 12 mL of fluid)

Question 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.

Answer 64

A, B, & E

Question 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.

Answer 65

B. Withhold the blood transfusion.

Question 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.”

Answer 66

A. When descending stairs, I will first shift my weight to my right leg.

Question 67

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

Answer 67

B. 0.3 mg

Question 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.

Answer 68

C. Bladder scan shows 525 mL of urine.

Question 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

Answer 69

A. Erythema on pressure points

Question 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.

Answer 70

B. Tell the client to keep the head of the bed elevated at least 30’.

Question 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.

Answer 71

D. Compare prescriptions with medications the client received while at the facility.

Question 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.”

Answer 72

C. I flushed what I urinated at 7am and have saved all urine since. (client should discard first voiding and save all subsequent voidings.)

Question 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.

Answer 73

D. You should receive a pneumococcal vaccine when you are 65 years old.

Question 74

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

Answer 74

C. Rapid heart rate

Question 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.

Answer 75

A. Instruct the clients family to refrain rom pushing the button for the client while she is asleep.

Question 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

Answer 76

B. A client who smokes one pack of cigarettes each day

Question 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.

Answer 77

C. You should have a fecal occult b blood test every year.

Question 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.

Answer 78

D. Initiate an enteral feeding through a gastrostomy tube.

Question 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.

Answer 79

D. I will be sure to remove my hearing aid before taking a shower.

Question 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.

Answer 80

D. Apply an ankle-foot orthotic device to the clients feet.

Question 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.

Answer 81

B. Wrap monitoring cords with stockinette and tape them in place.

Question 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?

Answer 82

The caregiver insists on remaining in the room.

Question 83

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.

Answer 83

A. Auscultate lung sounds.

Question 84

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

Answer 84

A. Walking briskly

Question 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?

Answer 85

We can talk about advance directives, and I can also give you some brochures about them.

Question 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

Answer 86

D. A client who has asthma

Question 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

Answer 87

A. I can take echinacea to improve my immune system.

Question 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.

Answer 88

A. Gently shake the container of the medication prior to administration.

Question 89

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

Answer 89

D. Practice sessions

Question 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.

Answer 90

B. Select a suction catheter that is half the size of the lumen.

Question 91

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

Answer 91

C. Current medications

Question 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.

Answer 92

B. An x-ray shows the end of the tube above the pylorus.

Question 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.

Answer 93

A. The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field.

Question 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.

Answer 94

B. A nurse asks a nurse from another unit to assist with documentation for a client.

Question 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.

Answer 95

D. People in middle adulthood often find satisfaction in nurturing and guiding young people.

Question 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.

Answer 96

D. Arrange food in a consistent pattern on the clients plate.

Question 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.

Answer 97

B. Witness the clients signature on the consent form.

Question 98

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

Answer 98

B. N95 respirator

Question 99

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

Answer 99

C. Skin blanching

Question 100

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.

Answer 100

C. Evacuate the client.

Question 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.

Answer 101

C. Assess the client for orthostatic hypotension.

Question 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.

Answer 102

B. The pain is like a dull ache in my stomach.

Question 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.

Answer 103

C. Have the client stand with their arms at their sides and their feet together.

Question 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?

Answer 104

A. What could I have done to deserve this illness?

Question 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.

Answer 105

A. Wrap blankets around all four sides of the bed.

Question 106

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

Answer 106

C. Medication dose

Question 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.

Answer 107

A. A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively.

Question 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.

Answer 108

D. Have the client use a trapeze bar when changing position.

Question 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.

Answer 109

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)

Question 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.

Answer 110

B. Maintain a consistent time to wake up each day.

Question 111

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

Answer 111

D. Distended neck veins