ATI Predictor Comprehensive Assessment 2019 A,100% CORRECT

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ATI Predictor Comprehensive Assessment 2019 A A nurse is teaching a client who has a new prescription for metformin extended release tablets. Which of the following statements by the client indica... tes an understanding of the teaching? a. I will avoid crushing this medication A nurse is assessing a client who is receiving enteral feeding via an NG tube. The client has developed hyperosmolar dehydration. Which of the following actions should the nurse take when administering the client’s findings? a. Switch to a lactose-free formula. A nurse is providing discharge teaching to a client who has a new ostomy. Which of the following instructions should the nurse include? a. Empty your ostomy pouch when it is half full A nurse is teaching the parents of a school-age child who has sickle cell anemia about managing the disease at home which of the following instructions should the nurse include? a. Apply cold compresses too painful areas A nurse is teaching about Safe Handling of formula to a client who is postpartum and chooses to bottle feed her newborn. Which of the following statements by the client indicates an understanding of the teaching? a. I should boil tap water for 2 minutes and call it before I mix it with powdered formula A nurse is assessing a child who is post-operative following a tonsillectomy. Which of the following findings should the nurse identify as the priority? a. Frequent swallowing A nurse is teaching a client who is pregnant about non-stress testing. Which of the following statements by the client indicates an understanding of the teaching? a. During this test, I will punch a button if the baby moves A nurse is monitoring a client who is receiving a transfusion of packed RBC's. The client reports chills, headaches, low back pain, and a feeling of tightness in his chest. The nurse should identify that the client has developed which of the following types of transfusion reactions? a. Acute hemolytic A nurse is caring for a client who is in the latent phase of Labor and reports severe back pain. The vaginal examination reveals that the cervix is dilated two centimeters, 25% effaced and -2 station. Which of the following interventions should the nurse implement? 1. Request the provider prescribe a pudendal nerve block A nurse is teaching about how to suppress lactation with a client who is postpartum and bottle feeding her newborn. Which of the following instructions should the nurse include in the teaching? a. You should wear a snug fitting bra continuously for 72 hours A nurse is preparing to administer medication to a client. What are the following identifiers should the nurse use to identify the client? a. Room number A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a seated position. Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension? a. The clients systolic blood pressure decreases by 25 mmHg While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm of the ventilator sounds. Which of the following actions should the nurse take? a. Look for a leak in the tubes cuff A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take first? a. Position the sterile drape leaving the perineum exposed A nurse is planning to administer packed RBC's to an older adult client who has a low hemoglobin level. Which of the following actions should the nurse plan to take? a. Monitor Vital Signs every hour throughout the transfusion A new nurse in an acute mental health facility is teaching a client about potential adverse effects of transcranial magnetic stimulation. The nurse tells the client that he might not feel light-headed but that it should not affect his memory. The nurse is demonstrating which of the following ethical principles? a. Beneficence A nurse is teaching a class about providing care within the legal scope of practice to a group of nurses. The nurse should include that which of the following procedures is outside the legal scope of practice for an RN? a. Irrigation of the external ear canal A nurse in an acute care facility is caring for a client who has anorexia nervosa. During the first week of care, which of the following actions should the nurse take? a. Observe the client for 1 hour after meals A nurse is planning care for a client who has sciatica and a prescription for a transcutaneous electrical nerve stimulation (TENS) unit. Which of the following referral should the nurse anticipate for the client? a. Physical therapist A nurse is teaching a client who has generalized anxiety disorder about ways to help manage stress. Which of the following instructions should the nurse give the client about using Progressive relaxation? a. Tighten the muscle group, then release tension and move to the next one A nurse is assessing a client who is at 37 weeks of gestation and reports sudden, severe abdominal pain with moderate vaginal bleeding and persistent uterine contraction. The client's blood pressure is 88 over 50 mmhg and her abdomen is rigid. The nurse should identify these findings as indicating which of the following complications? a. Placenta abruption A home health nurse is planning care for an older adult client who has a vision loss and takes medication throughout the day. Which of the following actions should the nurse include in the plan? a. Use container Lids of different shapes to indicate times of Administration A nurse is planning care for a client who has a history of urinary tract infections UTIs and requires placement of an indwelling catheter. Which of the following actions should the nurse take to help minimize the client's risk of acquiring a UTI? a. Whoop the tubing so that is lower than the collection bag b. keep urine a bag at bladder level when ambulating c. secure the catheter to the client’s thigh d. obtain urinary samples by disconnecting the tubing connections A nurse at an acute care facility is teaching a client about fall risk prevention strategies for use during their stay at the facility. Which of the following statements by the client indicates an understanding of the teaching? a. I will wear a yellow wristband, so everyone knows I'm at risk for falling A nurse is caring for a client who is taking disulfiram for alcohol-use disorder and reports ingestion of alcohol. For which of the following adverse effects should the nurse monitor? a. Headache A nurse at the health department is providing anticipatory guidance to a parent of a one month or a year-old infant. The nurse should inform the parent that the infant should receive which of the following immunizations at the age of two months? a. Rotavirus A Nurse is assisting in the selection of foods for a client who has dysphagia caused by a stroke. Which of the following foods should the nurse recommend? a. Scrambled eggs A community health nurse is providing education to a group of older adults about immunizations. Which of the following immunizations should the nurse recommend? a. Tdap A nurse is caring for a client who is postoperative following a mitral balloon valvuloplasty. Which of the following areas should the nurse auscultate to assess for mitral areas of the heart? (you will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) A nurse is planning care for a client who is experiencing benzodiazepine toxicity. The nurse should plan to administer which of the following medications? a. Flumazenil A nurse is admitting a client to the medical-surgical unit. The patient self-determination act requires the nurse to perform which of the following actions during the admission process? Document in the client's medical record is a client has advance directives A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an indication of paralytic Ileus? a. Abdominal distension A nurse is performing an administered admission assessment of a school-age child who has spina bifida. the parents state that a child is allergic to latex. The nurse should assess further for cross sensitivity to which of the following Foods? a. Bananas A nurse is planning care for a client who is at 32 weeks of gestation and has severe pre- eclampsia. Which of the following actions should the nurse plan to take? a. Ensure that the side rails are up on the client's bed A nurse is documenting admission data for a client in an acute care facility. Which of the following actions should the nurse take? a. Note whether the client has a living will A client on an acute mental health unit states to a nurse, tie a bow. Row the boat. Now I know. Whoa! I see you, you the nurse should document that the client is exhibiting which of the following speech alterations? a. Clang Association A nurse is caring for a client who has Crohn's disease. The nurse calculates that the client BMI is 17.2. The nurse should document that the clients wait status is being within which of the following categories? a. Underweight A nurse is planning post-operative care for a client who is scheduled for a thoracotomy with chest tube placement. Which of the following pieces of equipment should the nurse plan to have at the client's bedside? a. Tracheostomy tray A nurse is providing discharge teaching to a client who has Gerd. Which of the following information should the nurse include? a. Avoid consuming foods containing chocolate A nurse is part of a task force planning to audit a facilities nursing unit concerning adherence to hand hygiene protocols. Which of the following steps should the task force take first? a. Determine the accepted standards for hand hygiene A nurse is planning educational materials for a client who has a new pacemaker. Which of the following information should a nurse include? a. Keep mobile phones 4 inches from the pacemaker generator A nurse is providing discharge teaching to a client who is 1-day postoperative following a right modified radical mastectomy. Which of the following instructions should the nurse include in the teaching? a. Avoid using the affected arm for eating A nurse is planning care for a client prior to an amniocentesis. Which of the following actions should the nurse include in the plan of care? a. Monitor the fetal heart rate throughout the procedure A nurse is assessing a 24-month-old toddler at a well-child checkup. Which of the following findings indicates to the nurse that the toddler has a developmental delay? a. Runs with a wide stance A nurse in an emergency department is administering naloxone to a client who had a heroin overdose. The nurse should identify which of the following assessment findings as an indication that the medication is reversing the effects of the opioid overdose? a. Increase respiratory rate A nurse is caring for a client following an involuntary admission to an acute mental health facility. The client states, I'm afraid they will give me drugs that put me to sleep. Which of the following statements should the nurse make? a. Why do you think your provider will prescribe you medication’s that will make you sleep? A nurse is caring for a client who is preoperative for cataract removal. Which of the following statements by the client indicates an understanding of the procedure? a. I can expect my eyelids to be bruised after this procedure A nurse is planning care for a client who is undergoing brachytherapy for a low dose radiation implant for treatment of prostate cancer. Which of the following interventions should the nurse include in the client's plan of care? a. Limit each of the client’s visitors to two hours per day A nurse is teaching a client about using transdermal scopolamine to treat motion sickness. Which of the following instructions should the nurse include? a. Apply the patch prior to traveling A nurse is admitting a school-age child who has bacterial meningitis. Which of the following types of isolation precautions should the nurse initiate? a. Droplet A nurse is planning assignments for an upcoming shift. Which of the following tasks should the nurse delegate to an assistive Personnel? (select all that apply.) a. Record a client's intake after each meal b. Transfer a client to physical therapy c. Obtain the client's Vital Signs every 4 hours A nurse is interpreting a cardiac Rhythm strip from a client who has recurrent episodes of syncope. Which of the following images indicates the client has atrial fibrillation? A community health nurse is planning an educational program on Lyme disease or the general public. Which of the following statements should the nurse include in the program? a. Remove embedded Ticks by squeezing the body with tweezers A nurse is admitting a client to the medical-surgical unit. The patient self-determination act requires the nurse inform which of the following actions during the admission process? a. Document in the client's medical records if the client has advance directives A nurse is teaching a client how to care for his behind the ear hearing aid. Which of the following statements by the client indicates an understanding of the teaching? a. I'll disconnect the battery when I remove my hearing aids a nurse is caring for a client who is postpartum and expresses concern about how her preschool-age son will react to having a baby sister. Which of the following strategies should the nurse suggest? a. Give your son a little gift from his new sister A nurse is caring for a 3-year-old toddler who has dehydration. Which of the following findings should the nurse report to the provider? a. Potassium 3.9 mEq / L A nurse is teaching a class about using niacin to reduce LDL cholesterol. The nurse should include in the teaching that which of the following conditions is a contraindication for receiving this medication? a. Active liver disease a school nurse is using the Weber test to check a child. Which of the following actions should the nurse take? a. Place a vibrating tuning fork on the top of the child's head A nurse is reviewing the medical record of a client who has a prescription for misoprostol for induction of Labor. Which of the following findings is a contraindication for administration of this medication? a. Transverse fetal lie A nurse is reviewing the results of laboratory screenings for a nine-month-old infant. Which of the following results should the nurse report to the provider? a. Iron 74 mcg / dL. A nurse is teaching a client who has a new prescription for sertraline to treat depression. For which of the following findings should the nurse instruct the client to Monitor and Report immediately as indicating serotonin syndrome? a. Excessive sweating A community health nurse is developing a plan of care for an older adult client who has Type 2 diabetes mellitus and lives independently in a Royal area. Which of the following interventions should the nurse include? a. Instruct the client about the use of Telehealth services A nurse in a provider's office is monitoring the laboratory results of a client who has type 1 diabetes mellitus. Which of the following results and the case of the client demonstrates acceptable glycemic control? a. Hba1c 6.8% A nurse is providing dietary teaching to the guardian of a preschooler who has celiac disease. Which of the following foods should the nurse recommend including the preschoolers’ diet? a. A corn tortilla with black beans A nurse is caring for a client who has a peritoneal catheter that requires a dressing change. Identify the sequence of actions the nurse should take. (the steps into the box on the right, placing them in the order of the performance. Using all the steps.) a. 2nd- Remove the old dressing b. 4th- Cleanse the site with povidone-iodine c. 1st- Mask self and the client d. 5th- Apply precut gauze pads to the site e. 3rd- Create a sterile field A case manager is performing a home visit for a client following a stroke. The client’s partner is providing care in the home. The client's partner states that she sometimes feels exhausted. For which of the following referral should the case manager recommend for the caregiver? a. Respite care A nurse is reviewing the laboratory results of a client who is receiving Total parenteral Nutrition. Which of the following results should the nurse identify as an identification for the client has developed a common complication of this nutritional therapy? a. Capillary glucose 198 mg / DL a nurse is teaching a newly licensed nurse about advance directives. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. Patient can resume control of health care after a temporary loss of competency A nurse is assessing a client for an allergy spider administering the Influenza vaccine. The nurse should identify that an allergy to which of the following Foods is a contraindication to receiving this vaccine? a. Eggs A nurse is caring for a client who has deep vein thrombosis and a new prescription for an anti- embolic stocking. Which of the following actions should the nurse take? a. Measure the legs with a tape measure to determine stocking size A nurse is inserting a short peripheral IV catheter for a client who is requires IV fluids. Which of the following actions should the nurse take? a. Select a site proximal to previous venipuncture sites A charge nurse is evaluating a newly licensed nurse who is caring for a client who has measles. Which of the following actions by the newly licensed nurse should the charge nurse intervene? a. The nurse wears an N95 respirator when performing client care A nurse is caring for a client who is 2 days postpartum. Which of the following findings should the nurse report to the provider? a. 4 + deep tendon reflexes A nurse is observing an assistive Personnel (AP) measure blood pressure from the right arms of the group of clients. The nurse should instruct the AP to measure the blood pressure in the left arm of which of the following clients? a. A client who had dialysis and is using an arteriovenous shunt in the left lower forearm A nurse is caring for a female client who requires bed rest and reports difficulty urinating into a bedpan. Which of the following actions should the nurse take? a. Turn on the faucet in the client's sink A charge nurse observes smoke coming from a trash receptacle and the units waiting room. Which of the following actions should the nurse take first? a. Evacuate clients from the area A nurse is caring for a client who has diabetic ketoacidosis. During the shift, the client receives 0.45% sodium chloride IV at 500 mL over hours for 3 hours. Then at 200 mL/ hour for 3 hours. And then dextrose 5% in water at 75 mL / hour for 2 hours. What is the total volume the nurse should document for the client’s IV fluid intake? (round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 1250_mL A nurse is teaching a client who is at 20 weeks of gestation about how to manage Harbor. Which of the following instructions should the nurse include? a. Eat a high-fiber snack at bedtime A nurse is assessing a client who is taking Digoxin to treat chronic heart failure. Which of the following findings should indicate to the nurse that the client is developing Digoxin toxicity? a. Blurred vision A charge nurse is observing an assistive Personnel perform delegated tasks. What of the following actions by the AP requires a charge nurse to intervene? a. Washing hands with alcohol-based hand rub after bathing a client who has c-diff a nurse is caring for four children in an emergency department. Which of the following clients should the nurse assess first? a. A child who has acute epiglottitis and is drooling 1. A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a kidney transplant. Which of the following findings should the nurse report? a. Serum creatinine 1.6 mg/dL 2. A nurse is providing discharge instructions about a newborn safety to a client who is 2 days postpartum. Which of the following instructions should the nurse include? a. Use a car seat when traveling by airplane. 3. Math question 4. A nurse is caring for a client who has major depressive disorder. The client tells the nurse, “No one cares about me. I’m completely alone”. Which of the following responses should the nurse make? a. “Can you give me an example of how others are making you feel this way?” 5. A nurse on a medical-surgical unit is caring for a client who states that she plans to leave the facility against medical advice. For which of the following actions by the nurse should the charge nurse intervene? a. Asks security to detain the client until the provider is notified 6. A nurse is a prenatal teaching to a client who is at 12 weeks of gestation. The nurse should tell the client she will undergo which of the following screening tests at 16 weeks of gestation? a. Maternal serum alpha-fetoprotein 7. A nurse is admitting a client who has schizophrenia and experiences occasional auditory hallucinations. The client states, “It’s hard not to listen to the voices.” Which of the following questions should the nurse ask the client? a. “Do you understand that the voices are not real?” 8. A nurse is planning care for a client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse include to support the client’s nutritional requirements? a. Maintain calorie intake at 1,500 per day 9. A charge nurse is preparing to lead negotiations among nursing staff due to a conflict about overtime requirements. Which of the following strategies should the charge nurse use to promote effective negotiation? a. Attempt to understand both sides of the issue 10. A nurse is preparing to administer a NG tube feeding to a school-age child. Which of the following actions should the nurse plan to take? a. Measure the tubing from the nose to the distal port 11. A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? a. Monitor the FHR via Doppler every 30 min 12. A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first? a. Measure the client’s vital signs 13. A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include? a. Excessive sweating 14. A nurse is caring for a client who is postoperative and has a chest tube drainage system. For which of the following findings should the nurse notify the provider? a. Tidaling occurs when the client is breathing 15. A nurse is preparing to administer vancomycin IV to an adult. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make? a. “I can start the medication 30 min earlier.” 16. A nurse in the emergency department is interviewing a client immediately following a sexual assault. Which of the following actions should the nurse take first? a. Determine a client’s current anxiety level 17. A nurse is caring for a client who gestational hypertension and is experiencing toxic effects due to magnesium sulfate therapy. The nurse should anticipate administering which of the following medications? a. Calcium gluconate 18. A nurse is caring for a client who has end-stage kidney disease. The client’s adult child asks the nurse about becoming a living kidney donor for their parent. Which of the following conditions in the child’s medical history should the nurse identify as a contraindication to the procedure? a. Hypertension 19. A nurse has identified tasks to delegate to a group of assistive personnel (AP) after receiving change-of-shift report. Identify the sequence of steps the nurse should follow when delegating tasks to the Aps. Put in order - 1st Review the skill level and qualifications of each AO - 3rd Monitor progress of tasks completion with each AP - 4th Evaluate the APs’ performance of each task - 2nd Communicate appropriate tasks to the APs with specific expectations 20. A nurse is preparing to perform sterile wound irrigation and dressing change for a client. Which of the following actions by the nurse indicates a break in surgical aseptic technique? a. Balancing the bottle on the sterile basin while pouring the liquid 21. A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? a. “We should establish our roles in the initial session.” 22. A nurse is caring for a client who is receiving intermittent enteral tube feeding. Which of the following factors places the client at risk for aspiration? a. A history of gastroesophageal reflux disease 23. A nurse is caring for a client who is 4 hr postpartum. The client reports an urge to void but is unable to void. Which of the following actions should the nurse take? a. Encourage the client to attempt to void while using a Sitz bath 24. A nurse is caring for a client who has preeclampsia and is experiencing a postpartum hemorrhage. The nurse should expect the provider to prescribe which of the following medications? a. Oxytocin 25. A nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse include in the teaching? a. “This test should be performed after your baby is 24 hours old.” 26. A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching? a. Documenting communication with a provider in the progress notes of the client’s medical record 27. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse assess first? a. A client who has a hip fracture and a new onset of tachypnea 28. A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan to take? a. Secure the urinary catheter to the client’s thigh 29. A nurse is planning care for a group of clients. Which of the following methods should the nurse use to manage time effectively? a. Gather supplies prior to completing a dressing change 30. A nurse is preparing to assist the provider with a paracentesis for a client who has ascites. Which of the following actions should the nurse plan to take? a. Have the client void prior to the procedure 31. A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching? a. “I can visit my nephew who has chickenpox 5 days after the sores have crusted.” 32. A nurse is caring for a school-age child who has sickle cell anemia and is in vaso- occlusive crisis. Which of the following actions should the nurse take? a. Increase oral fluid intake 33. A nurse is assessing a client who is 2 hr postpartum for uterine atony. Which of the following actions should the nurse take? a. Palpate the client’s fundus 34. A nurse manager is reviewing documentation with a newly licensed nurse. Which of the following notations by the newly licensed nurse indicate an understanding of the teaching? a. “OOB with assistance for breakfast.” 35. A charge nurse is teaching new staff members about factors that increase a client’s risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence? a. Previous violent behavior 36. A nurse is teaching a wellness class about depression for a group of older adult client. Which of the following information should the nurse include in the teaching? a. Depression can be misdiagnosed as a neurocognitive disorder in older adult clients 37. A nurse is assessing a client who is receiving morphine IV for pain. Which of the following findings should the nurse report the provider first? a. BP 80/40 mm Hg 38. A nurse is providing discharge teaching to a client who is postoperative following surgery for carpal tunnel syndrome. Which of the following statements by the client indicated an understanding of the teaching? a. “I should not use my affected hand for 4 to 6 weeks.” 39. A nurse is using an IV pump for a newly admitted client. Which of the following actions should the nurse take? a. Check the cords of the IV pump for fraying 40. A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan? a. Place the client left arm on a pillow while he is sitting 41. A nurse on a pediatric unit is preparing to insert an IV catheter for a 7-year-old child who is dehydrated. Which of the following actions should the nurse take? a. Tell the child there will be discomfort during the catheter insertion 42. A nurse is caring for a client who has acute glomerulonephritis. The nurse should identify that which of the following findings is the priority? a. BUN 24 mg/dL 43. A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is the priority for the nurse to report to the provider? a. Hypotension 44. A nurse is reviewing the medical record of a client. Which of the following findings should the nurse report to the provider? EXHIBIT a. Temperature 45. A nurse in the infectious disease division of the local health department is caring for a client. Which of the following infections should the nurse identify should be reported to the health department? a. Chlamydia trachomatis 46. A nurse in a family practice clinic is screening an adolescent client for idiopathic scoliosis. Which of the following assessments should the nurse perform as part of this screening? a. Measure the truncal rotation 47. A nurse is assessing an older adult client who had left-sided stroke. Which of the following findings should the nurse expect? a. Expressive aphasia 48. A nurse is preparing to teach the parents of a child who has cystic fibrosis. Which of the following instructions should the nurse plan to include? a. Provide a diet high in protein and calories 49. A nurse is reviewing the medical records of four clients. The nurse should identify which of the following client findings requires follow-up care? A client who received a Mantoux test 48 hr ago and has an induration 1. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include? a. Consume foods high in bran fiber 2. A nurse is planning care for a client who has an L4 spinal cord injury. Which of the following interventions to prevent skin breakdown should the nurse include in the plan of car? a. Ask the client to shift his weight every 20 min while sitting in a chair 3. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained verbal prescription for mechanical restraints. Which of the following actions should the nurse take? a. Assess the clients peripheral pulse rate every 30 min 4. A nurse is teaching a guardian of an adolescent who has mild persistent asthma and a new prescription for maintenance prednisone. Which of the following statements by the guardian indicated an understanding of the teaching? a. “This medication can increase my son’s risk for infection 5. A charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following examples should the charge nurse include in the teaching? a. Keeping the side-rails of a toddler’s crib elevated 6. A nurse is reviewing assessment data from several clients. For which of the following clients should the nurse recommend referral to a dietician? a. A client who has a on a nonhealing leg ulcer 7. A nurse is assessing a client who is 1 day postoperative following the placement of an ileostomy. Which of the following findings should the nurse report to the provider? a. The stoma has a purplish hue 8. A nurse is caring for a client who is obese. The client is crying and states, “Everyone is staring at me because of my weight.” Which of the following responses should the nurse make? a. “Have you always felt uncomfortable being overweight?” 9. A nurse is preparing educational material for a client. Which of the following techniques should the nurse use in creating the material? a. Write information at a seventh-grade reading level 10. A nurse is caring for a client who has a new prescription for warfarin. When reviewing the client’s current medication, which of the following medications should the nurse identify as contraindicated for use with warfarin? (Select All That Apply) a. Ibuprofen b. Gingko biloba c. Aspirin 11. A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching? a. Eat 1g/kg of protein per day 12. A nurse is performing gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following actions should the nurse take? a. Insert a large-bore NG tube 13. A nurse is reading a tuberculin skin test for a client who received a purified protein derivative test 72 hr ago. Which of the following findings indicates a positive test? a. An induration measuring 5 mm 14. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor which of the following complications? a. Contractions 15. A nurse is reviewing the medication administration record of a client. Which of the following prescriptions should the nurse clarify? a. Digoxin .250 PO daily 16. A nurse is caring for a client who is at 38 weeks of gestation, is in active labor, and has ruptured membranes. Which of the following actions should the nurse take? a. Apply a fetal heart rate monitor 17. A nurse is assessing a client who is receiving daily aspirin therapy. The nurse should identify that which of the following findings might indicate an allergic reaction to this medication? a. Difficulty swallowing 18. A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine? a. WBC count 2,900/ mm3 19. A nurse is providing teaching about crutch safety to a client. Which of the following client actions indicated an understanding of the teaching? a. The client places the crutches 30 cm (12 in) to the front and side of each foot while standing 20. A nurse is teaching a newly licensed nurse about incident reports. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. “They assist with unit quality improvement.” 21. A nurse is providing dietary teaching to a client who has chronic kidney disease. Which of the following instructions should the nurse include? a. Restrict foods containing phosphorus 22. A nurse is caring for a group of clients who have chronic pain. Which of the following clients should the nurse identify as a candidate for occupational therapy? a. A client who has painful hands due to degenerative joint disease 23. A nurse is teaching a client who has chronic urinary tract infection. Which of the following instructions should the nurse include? a. Drink at least 1 L of fluid everyday 24. A nurse is speaking with the partner of a client who is the early stage of Alzheimer’s disease. The partner tells the nurse that she is able to manage the client’s physical care, but she doesn’t want to leave him alone while she travels for work. Which of the following referrals should the nurse make? a. Respite care 25. A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching? a. “Have your child drink a small glass of water after swallowing the medication.” 26. A nurse is caring for a client who is recovering from an amputation of her right arm below the elbow. Which of the following information should the nurse report to the occupational therapist? a. The client has two small children at home 27. A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first? a. Palpate the pulse distal to the cast 28. A nurse is preparing to assist with the lumbar puncture of an infant. The nurse should plan to place the infant in which of the following positions? a. Flexed side lying 29. Math question 30. A newly licensed nurse is unsure if an assigned task is within their scope of practice. Which of the following resources should the nurse consult? a. State Nurse Practice Act 31. A nurse is caring for client who is experiencing a diazepam overdose. Which of the following medications should the nurse administer? a. Flumazenil 32. A community health nurse is reviewing laboratory reports for a group of clients. The nurse should identity that which of following disorder is on the CDC’s Nationally Notifiable Conditions list? a. Lyme disease 33. A nurse manger is developing a protocol for staff discipline. Which of the following actions should the nurse manger take when implementing this new protocol? a. Inform staff about the purpose of the unit’s new processes. 34. A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods while taking this medication? a. Whole grain bread 35. A nurse is administering a continuous enteral feeding to a client. Which of the following actions should the nurse Take? a. Return aspirate residuals 300 mL or less. 36. A nurse is urgent care clinic is caring for infant who presents with vomiting, diarrhea, and decreased oral intake. Which of the following manifestations should the nurse expect? a. Oliguria 37. A nurse is teaching a newly licensed nurse about postpartum hemorrhage. Which of the following statements by the new licensed nurse indicates an understanding of the teaching? a. “Postpartum hemorrhage can occur within the first 6 weeks after delivery.” 38. A Nurse Manager is updating protocols for the use of belt restraints. Which of the following guideline should the nurse manager include? a. Document the client’s condition every 15 min. 39. A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? a. Perform the procedure prior to meals 40. A nurse on medical-surgical unit is performing medication reconciliation for newly admitted client. Which of the following actions should the nurse take? a. Compare the client’s list of home medications to the admission prescriptions written for the client. 41. A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? a. “The client exhibits impulsive behavior.” 42. A nurse is teaching a client who is pregnant and has a new prescription for an iron supplement. Which of the following statement should the nurse include? a. “You might become constipated while taking this medication.” 43. A nurse is caring for a client who has cancer of the throat findings is receiving and is receiving radiation therapy. The nurse should monitor for which of the following findings as an adverse effect of the radiation? a. Altered taste sensation 44. A nurse is caring for client who is febrile. To reduce the client’s fever, the nurse applies a cooling blanket. Which of the following findings indicates the client is having an adverse reaction to the cooling”? a. Shivering 45. A nurse is caring for an infant who has respiratory syncytial virus. Which of the following intervention should the nurse take? a. Suction nares prior to feeding 46. A nurse is for a client who is wearing anti-embolic stockings. Which of the following interventions should the nurse include in the plan of care? a. Fold the top of the stockings over neatly 50. A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a kidney transplant. Which of the following findings should the nurse report? b. Urine specific gravity 1.023 c. Serium creatinine 1.6 mg/dL d. Urine pH 6.2 e. BUN 18 mg/dL 51. A nurse is providing discharge instructions about a newborn safety to a client who is 2 days postpartum. Which of the following instructions should the nurse include? b. Use a car seat when traveling by airplane. c. Lay the baby on his stomach to nap during the daytime. d. Change smoke detector batteries every other year e. Place a plastic waterproof sheet over the crib bedding 52. Math question 53. A nurse is caring for a client who has major depressive disorder. The client tells the nurse, “No one cares about me. I’m completely alone”. Which of the following responses should the nurse make? b. “What makes you think that”? c. “Can you give me an example of how others are making you feel this way?” d. “You should join a community support group.” e. “Don’t worry. You should be feeling better in a couple weeks.” 54. A nurse on a medical-surgical unit is caring for a client who states that she plans to leave the facility against medical advice. For which of the following actions by the nurse should the charge nurse intervene? b. Asks the client to sign a form releasing the hospital from legal responsibility c. Asks security to detain the client until the provider is notified d. Show the client for abnormal laboratory results e. Asks the client what her plans are for follow-up care 55. A nurse is a prenatal teaching to a client who is at 12 weeks of gestation. The nurse should tell the client she will undergo which of the following screening tests at 16 weeks of gestation? b. Maternal serum alpha-fetoprotein c. Nonstress test d. Cervical cultures for chlamydia e. Chorionic villus sampling 56. A nurse is admitting a client who has schizophrenia and experiences occasional auditory hallucinations. The client states, “It’s hard not to listen to the voices.” Which of the following questions should the nurse ask the client? b. “Have you tried going to a private place when this occurs?” c. “What helps you ignore what are you hearing?” d. “Do you understand that the voices are not real?” e. “Why do you think the voices are talking to you?” 57. A nurse is planning care for a client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse include to support the client’s nutritional requirements? b. Keep a calorie count for foods and beverages c. Maintain calorie intake at 1,500 per day d. Schedule meals at 6-hr intervals e. Provide a low-protein, high-carbohydrate diet 58. A charge nurse is preparing to lead negotiations among nursing staff due to a conflict about overtime requirements. Which of the following strategies should the charge nurse use to promote effective negotiation? b. Identify solutions prior to negotiation c. Personalize the conflict d. Attempt to understand both sides of the issue e. Focus on how the conflict occurred 59. A nurse is preparing to administer a NG tube feeding to a school-age child. Which of the following actions should the nurse plan to take? b. Position the child at a 10 to 20 degree angle after feeding c. Warm the formula in the microwave d. Complete the feeding in 5 min e. Measure the tubing from the nose to the distal port 60. A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? b. Monitor the FHR via Doppler every 30 min c. Measure the clients urine output every hour d. Restrict the clients total fluid intake to 250mL/hr e. Give the client protamine if signs of magnesium sulfate toxicity occur 61. A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first? b. Notify the provider c. Measure the clients vital signs d. Report the incident to the nurse manager e. Fill out an incident report 62. A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first? a. Notify the provider b. Measure the clients vital signs c. Report the incident to the nurse manager d. Fill out an incident report 63. A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include? b. Increased urinary frequency c. Dry cough d. Excessive sweating e. Metallic taste in the mouth 64. A nurse is caring for a client who is postoperative and has a chest tube drainage system. For which of the following findings should the nurse notify the provider? b. Tidaling occurs when the client is breathing c. Continuous bubbling in the water seal chamber d. Oxygen saturation of 92% on room air e. Presence of 50 mL/hr in the drainage chamber 65. A nurse is preparing to administer vancomycin IV to an adult. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make? b. “I can infuse the medication at a faster rate.” c. “I have up to 2 hours after the usual schedule time to give you this medication.” d. “I can adjust the time and schedule for when it’s convenient for you.” e. “I can start the medication 30 min earlier.” 66. A nurse in the emergency department is interviewing a client immediately following a sexual assault. Which of the following actions should the nurse take first? b. Determine a clients current anxiety level c. Initiate a referral for client counseling d. Request the clients permission to contact a family member e. Report the clients assault to the authorities 67. A nurse is caring for a client who gestational hypertension and is experiencing toxic effects due to magnesium sulfate therapy. The nurse should anticipate administering which of the following medications? b. Sodium bicarbonate c. Potassium chloride d. Calcium gluconate e. Magnesium sulfate 68. A nurse is caring for a client who has end-stage kidney disease. The client’s adult child asks the nurse about becoming a living kidney donor for their parent. Which of the following conditions in the child’s medical history should the nurse identify as a contraindication to the procedure? b. Hypertension c. Osteoarthritis d. Primary glaucoma e. Amputation 69. A nurse has identified tasks to delegate to a group of assistive personnel (AP) after receiving change-of-shift report. Identify the sequence of steps the nurse should follow when delegating tasks to the Aps. Put in order -Review the skill level and qualifications of each AO -Monitor progress of tasks completion with each AP -Evaluate the APs’ performance of each task -Communicate appropriate tasks to the Aps with specific expectations 70. A nurse is preparing to perform sterile wound irrigation and dressing change for a client. Which of the following actions by the nurse indicates a break in surgical aseptic technique? b. Applying a sterile gown after applying a sterile mask c. Putting on sterile gloves after preparing the sterile field d. Placing the supplies on the sterile field and leaving a 1-inch perimeter e. Balancing the bottle on the sterile basin while pouring the liquid 71. A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? b. “Lets talk about how you can change your response to stress.” c. “We should discuss resources to implement in your daily life.” d. “Let me show you simple relaxation exercises to manage stress.” e. “We should establish our roles in the initial session.” 72. A nurse is caring for a client who is receiving intermittent enteral tube feeding. Which of the following factors places the client at risk for aspiration? b. A residual of 65 mL 1 hr postprandial c. Receiving a high osmolality formula d. Sitting in high-fowlers position during the feeding e. A history of gastroesophageal reflux disease 73. A nurse is caring for a client who is 4 hr postpartum. The client reports an urge to void but is unable to void. Which of the following actions should the nurse take? b. Administer a diuretic to the client c. Massage the clients fundus d. Encourage the client to attempt to void while using a sitz bath e. Instruct the client to place her hands in cold water while attempting to void 74. A nurse is caring for a client who has preeclampsia and is experiencing a postpartum hemorrhage. The nurse should expect the provider to prescribe which of the following medications? b. Carboprost c. Methylergonovine d. Nifedipine e. Oxytocin 75. A nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse include in the teaching? b. “Your baby will be given 2 ounces of water to drink prior to the test.” c. “This test wull be repeated when your baby is 2 months old.” d. “This test should be performed after your baby is 24 hours old.” e. “A nurse will draw blood from your baby’s inner elbow.” 76. A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching? b. Placing a yellow bracelet on a client who is at risk for falls c. Leaving a nasogastric tube clamped after administering oral medication d. Documenting communication with a provider in the progress notes of the clients medical record e. Administering potassium via IV bolus 77. A nurse is receiving change-of-shift report for a group of client. Which of the following clients should the nurse assess first? b. A client who has diabetes mellitus and an HBA1c OF 6.8% c. A client who has a hip fracture and a new onset of tachypnea d. A client who ha sinus arrhythmia and is receiving cardiac monitoring e. A client who has epidural analgesia and weakness in the lower extremities 78. A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan to take? b. Obtain a 20 French indwelling urinary catheter c. Hang the drainage bag on the side rails of the bed d. Secure the urinary catheter to the clients thigh e. Clean the tubing from the connection toward the meatus 79. A nurse is planning care for a group of client. Which of the following methods should the nurse use to manage time effectively? b. Prioritize activities based on the nurses needs c. Complete partial assessments on all the clients before planning the day d. Use break time to perform documentation e. Gather supplies prior to completing a dressing change 80. A nurse is preparing to assist the provider with a paracentesis for a client who has ascites. Which of the following actions should the nurse plan to take? b. Have the client void prior to the procedure c. Obtain the client weight every 15 min during the procedure d. Place the client in a left side-lying position e. Monitor the drainage to ensure no more than 2 L of fluid is removed 81. A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching? b. “I should take antibiotics when I have a virus.” c. “I can visit my nephew who has a chickenpox 5 days after the sores have crusted.” d. “I should wash my hands for 10 seconds with hot water after working in the garden.” e. “I can clean my cats litter box during my pregnancy.” 82. A nurse is caring for a school-age child who has sickle cell anemia and is in vaso- occlusive crisis. Which of the following actions should the nurse take? b. Promote active range of motion exercises c. Prepare for a transfusion of platelets d. Apply cold compresses to the affected areas e. Increase oral fluid intake 83. A nurse is assessing a client who is 2 hr postpartum for uterine atony. Which of the following actions should the nurse take? b. Check the clients vital signs c. Monitor the clients urinary output d. Palpate the clients fundus e. Evaluate the clients pain level 84. A nurse manager is reviewing documentation with a newly licensed nurse. Which of the following notations by the newly licensed nurse indicate an understanding of the teaching? b. “OOB with assistance for breakfast.” c. “Administered 8 u regular insulin sq.” d. “Given 2 mg MSO4 IM for report of pain.” e. “Dressing changed qd.” 85. A charge nurse is teaching new staff members about factors that increase a client’s risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence? b. A history of being in prison c. Previous violent behavior d. Male gender e. Experiencing delusions 86. A nurse is teaching a wellness class about depression for a group of older adult client. Which of the following information should the nurse include in the teahing? b. Treatment options for depression are different for older adult clients than for clients in other age groups c. Changes in sleep patterns are not a manifestation of depression in older adult clients d. Depression can be misdiagnosed as a neurocognitive disorder in older adult clients e. Higher dosages of antidepressants are required to achieve therapeutic effects in older adult clients 87. A nurse is assessing a client who is receiving morphine IV for pain. Which of the following findings should the nurse report the provider first? b. BP 80/40 mm Hg c. Pupil diameter 6 mm d. Urinary Output 120/mL/4 hr e. Bowel movement 5 days ago 88. A nurse is providing discharge teaching to a client who is postoperative following surgery for carpal tunnel syndrome. Which of the following statements by the client indicated an understanding of the teaching? b. “I will need to keep my hand elevated above my heart for several days.” c. “I should not use my affected hand for 4 to 6 weeks.” d. “I should expect numbness and tingling in my hand.” e. “I can apply heat for the first 24 hours to minimize the pain in my hand.” 89. A nurse is using an IV pump for a newly admitted client. Which of the following actions should the nurse take? b. Check the cords of the IV pump for fraying c. Ensure that the electric outlet has two prongs for the IV pump d. Grasp the IV pump cord when unplugging it from the electrical outlet e. Remove the safety inspection sticker before plugging in the IV pump 90. A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan? b. Maintain the client on bed rest c. Provide total care in performing the clients ADLs d. Place the client left arm on a pillow while he is sitting e. Place food on the left side of the clients mouth when he is ready to eat 91. A nurse on a pediatric unit is preparing to insert an IV catheter for a 7-year-old child who is dehydrated. Which of the following actions should the nurse take? b. Perform the procedure in the child’s room c. Tell the child there will be discomfort during the catheter insertion d. Require the parents to leave the room during the procedure e. Use a mummy restraint to hold the child during the catheter insertion 92. A nurse is caring for a client who has acute glomerulonephritis. The nurse should identify that which of the following findings is the priority? b. Hematuria c. Weight gain of 3 kg (6.1 IB) d. BUN 24 mg/dL e. Fatigue 93. A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is the priority for the nurse to report to the provider? b. Tachycardia c. Dry cough d. Hypotension e. Dyspnea 94. A nurse is reviewing the medical record of a client. Which of the following findings shouls the nurse report to the provider? EXHIBIT b. Temperature c. Bowel sounds d. Prealbumin e. Urine specific gravity 95. A nurse in the infectious disease division of the local health department is caring for a client. Which of the following infections should the nurse identify should be reported to the health department? b. Chlamydia trachomatis c. Human papilloma virus d. Herpes simplex virus e. Clostridium difficlle 96. A nurse in a family practice clinic is screening an adolescent client for idiopathic scoliosis. Which of the following assessments should the nurse perform as part of this screening? b. Measure the truncal rotation c. Observe for sacral dimpling d. Measure the anteroposterior diameter of the chest e. Observe for positive Romberg sign 97. A nurse is assessing an older adult client who had left-sided stroke. Which of the following findings should the nurse expect? b. Loss of depth perception c. Expressive aphasia d. Left-sided weakness e. Poor judgement 98. A nurse is preparing to teach the parents of a child who has cystic fibrosis. Which of the following instructions should the nurse plan to include? b. Trim the fat from the red meat prior to cooking c. Provide a diet high in protein and calories d. Administer pancreatic enzymes 30 min after meals e. Give the child hot foods to reduce the sense of fullness 99. A nurse is reviewing the medical records of four clients. The nurse should identify which of the following client findings requires follow-up care? a. A client who received a Mantoux test 48 hr ago and has an induration b. A client who is taking bumetanide and has a potassium level of 3.6 mEq/L c. A client who is taking warfarin and has an INR of 1.8 d. A client who is scheduled for a colonoscopy and is taking sodium phosphate 47. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include? b. Increase intake of foods high in gluten c. Sweeten foods with fructose corn syrup d. Increase intake of milk products e. Consume foods high in bran fiber 48. A nurse is planning care for a client who has an L4 spinal cord injury. Which of the following interventions to prevent skin breakdown should the nurse include in the plan of car? a. Ask the client to shift his weight every 20 min while sitting in a chair b. Provide a high-fiber diet for the client c. Maintain the head of the bed at a 45 degree angle d. Massage reddened areas over bony prominences 49. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained verbal prescription for mechanical restraints. Which of the following actions should the nurse take? b. Document the clients condition and behavior every 25 min c. Request a renewal of the prescription every 8 hr d. Assess the clients peripheral pulse rate every 30 min e. Obtain a written prescription for the restraints within 4 hr 50. A nurse is teaching a guardian of an adolescent who has mild persistent asthma and a new prescription for maintenance prednisone. Which of the following statements by the guardian indicated an understanding of the teaching? b. “I should give this medication to my son when he starts to wheeze.” c. “This medication can increase my son’s risk for infection d. “I should have my son take this medication between meals.” e. “My son should avoid grapefruit juice while on this medication.” 51. A charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following examples should the charge nurse include in the teaching? b. Applying elbow immobilizers on an infant recovering from cleft lip surgery c. Placing a belt restraint on a school-age child who has seizure d. Keeping the side-rails of a toddlers crib elevated e. Securing wrist restraints to the bed rails for an adolescent 52. A nurse is reviewing assessment data from several clients. For which of the following clients should the nurse recommend referral to a dietician? b. A client who has an albumin level of 3.7 g/dL c. A client who has a on a nonhealing leg ulcer d. An older adult client who has presbyopia e. An older adult client who has a BMI of 24 53. A nurse is assessing a client who is 1 day postoperative following the placement of an ileostomy. Which of the following findings should the nurse report to the provider? b. Blood is present in the output c. The output is a dark green liquid d. The stoma bleeds slightly when touched e. The stoma has a purplish hue 54. A nurse is caring for a client who is obese. The client is crying and states, “Everyone is staring at me because of my weight.” Which of the following responses should the nurse make? b. “It sounds like you’re saying that you feel comfortable around others.” c. “Let’s discuss some weight loss strategies that might work for you.” d. “How long have you struggled with your weight?” e. “Have you always felt uncomfortable being overweight?” 55. A nurse is preparing educational material for a client. Which of the following techniques should the nurse use in creating the material? b. Use words with three or four syllables c. Avoid using cartoons in the teaching material d. Emphasize important information using bold lettering e. Write information at a seventh-grade reading level 56. A nurse is caring for a client who has a new prescription for warfarin. When reviewing the client’s current medication, which of the following medications should the nurse identify as contraindicated for use with warfarin? (Select All That Apply) d. Ibuprofen e. Magnesium sulfate f. Cetirizine g. Gingko biloba h. Aspirin 57. A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include un the teaching? b. Take magnesium hydroxide for indigestion c. Drink at least 3 L of fluid daily d. Consume foods high in potassium e. Eat 1 g/kg of protein per day 58. A nurse is performing gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following actions should the nurse take? b. Instruct the client to lie on his right side c. Insert a large-bore NG tube d. Instill 500 mL of solution through the NG tube e. Use a cold irrigation solution 59. A nurse is reading a tuberculin skin test for a client who received a purified protein derivative test 72 hr ago. Which of the following findings indicates a positive test? b. A reddened area measuring 5 mm c. An induration measuring 10 mm d. A reddened area measuring 10 mm e. An induration measuring 5 mm 60. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor which of the following complications? b. Contractions c. Vomiting d. Epigastric pain e. Hypertension 61. A nurse is reviewing the medication administration record of a client. Which of the following prescriptions should the nurse clarify? b. Acetaminophen 650 mg PO Q 6 hours c. Digoxin .250 PO daily d. Ceftriaxone 1 g IV Q 24 hours e. Levothyroxine 75 mcg PO daily at 0600 62. A nurse is caring for a client who is at 38 weeks of gestation, is in active labor, and has ruptured membranes. Which of the following actions should the nurse take? b. Initiate fundal massage c. Apply a fetal heart rate monitor d. Initiate an oxytocin IV infusion e. Insert an indwelling urinary catheter 63. A nurse is assessing a client who is receiving daily aspirin therapy. The nurse should identify that which of the following findings might indicate an allergic reaction to this medication? b. Blurred vision c. High blood pressure d. Weight gain e. Difficulty swallowing 64. A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine? b. Hgb 14 g/dL c. WBC count 2,900/ mm3 d. Heart rate 58/min e. Fasting blood glucose 100 mg/dL 65. A nurse is providing teaching about crutch safety to a client. Which of the following client actions indicated an understanding of the teaching? b. The client places the crutches 30 cm (12 in) to the front and side of each foot while standing c. The client flexes her elbows 10 degrees when supporting weight by using the handgrips d. The client keeps her axillae free of pressure e. The client leans on both crutches to support body weight 66. A nurse is teaching a newly licensed nurse about incident reports. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? b. “They assist the facility to achieve benchmark goals.” c. “They are mandatory government documentation.” d. “They are used as a disciplinary tool for nurse evaluations.” e. “They assist with unit quality improvement.” 67. A nurse is providing dietary teaching to a client who has chronic kidney disease. Which of the following instructions should the nurse include? b. Increase dietary intake of sodium c. Increase intake of high-potassium foods d. Limit iron supplements e. Restrict foods containing phosphorus 68. A nurse is caring for a group of clients who have chronic pain. Which of the following clients should the nurse identify as a candidate for occupational therapy? b. A client who has Alzheimer’s disease and is experiencing abdominal pain c. A client who has painful hands due to degenerative joint disease d. A client who has migraines and is experiencing nausea and vomiting e. A client who has a PCA for chronic pain following a laminectomy 69. A nurse is teaching a client who has chronic urinary tract infection. Which of the following instructions should the nurse include? b. Take tub baths instead of showers c. Drink at least 1 L of fluid everyday d. Wipe from back to front after a bowel movement e. Try to void every 4 hr 70. A nurse is speaking with the partner of a client who is the early stage of Alzheimer’s disease. The partner tells the nurse that she is able to manage the client’s physical care, but she doesn’t want to leave him alone while she travels for work. Which of the following referrals should the nurse make? b. Restorative care c. Hospice d. Respite care e. Rehabilitation facility 71. A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching? b. “Limit your child’s potassium intake while she is taking this medication.” c. “You can add the medication to a half-cup of your child favorite juice.” d. “Repeat the dose if your child vomits within 1 hour after taking the medication.” e. “Have your child drink a small glass of water after swallowing the medication.” 72. A nurse is caring for a client who is recovering from an amputation of her right arm below the elbow. Which of the following information should the nurse report to the occupational therapist? b. The client has two small children at home c. The client lives in a two-story home d. The client is allergic to penicillin e. The clients parent is in a skilled nursing facility 73. A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first? b. Teach the client to keep the cast clean and dry c. Place an ice pack over the cast d. Position the casted extremity on a pillow e. Palpate the pulse distal to the cast 74. A nurse is caring for a client following application of a cast. Which of the following action should the nurse Take First? a. Teach the client to keep the cast clean and dry. b. Place an ice pack over the cast. c. Position the casted extremity on a pillow. d. Palpate the pulse distal to the cast. 75. A nurse is preparing to assist with the lumbar puncture of an infant. The nurse should plan to place the infant in which of the following positions? b. Prone c. Trendelenburg d. Flexed side lying e. Seini fowler’s 76. Math question 77. A newly licensed nurse is unsure if an assigned task is within their scope of practice. Which of the following resources should the nurse consult? b. Written prescription for the provider. c. Verbal direction from the nurse manger d. State Nurse Practice Act e. Institutional policies and procedures 78. A nurse is caring for client who is experiencing a diazepam overdose. Which of the following medications should the nurse administer? b. Naltrexone c. Naloxone d. Disulfiram e. Flumazenil 79. A community health nurse is reviewing laboratory reports for a group of clients. The nurse should identity that which of following disorder is on the CDC’s Nationally Notifiable Conditions list? b. Lyme disease c. Bacterial vaginosis d. Respiratory syncytial virus e. Pediculosis capitis 80. A nurse manger is developing a protocol for staff discipline. Which of the following actions should the nurse manger take when implementing this new protocol? b. Promote staff adherence to new processes using strong consequences. c. Inform staff about the purpose of the unit’s new processes. d. Schedule disciplinary meetings at a time convenient for all parties e. Take nurse is providing discharge teaching to a client who has a new prescription for phenelzine. 81. A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods while taking this medication? b. Pepperoni pizza c. Smoked salmon d. Whole grain bread e. Avocados 82. A nurse is administering a continuous enteral feeding to a client. Which of the following actions should the nurse Take? b. Change the bag and tubing every 72 hr. c. Flush the tubing with 10ml of 0.9% folium chloride. d. Check gastric residual ever 4 hr. e. Returns aspirate residuals 300 ml or less. 83. A nurse is urgent care clinic is caring for infant who presents with vomiting, diarrhea, and decreased oral intake. Which of the following manifestations should the nurse expect? b. Hypertension c. Bulging anterior fontanel d. Decreased temperature e. Oliguria 84. A nurse is teaching a newly licensed nurse about postpartum hemorrhage. Which of the following statements by the new licensed nurse indicates an understanding of the teaching? b. “Postpartum hemorrhage from a cervical laceration is treated with terbutaline 0.25 milligrams subcutaneous.” c. “A woman is highest risk for postpartum hemorrhage during her first delivery.” d. “Postpartum hemorrhage can occur within the first 6 weeks after delivery.” e. “Inversion of the uterus is the leading cause of postpartum hemorrhage.” 85. A Nurse Manager is updating protocols for the use of belt restraints. Which of the following guideline should the nurse manager include? b. Request PRN restraint prescription for clients who are aggressive. c. Remove the client’s restraint every 4 hr. d. Document the client’s condition every 15 min. e. Attach the restraint to the bed’s side rails. 86. A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? b. Hold hand flat to perform percussions on the child. c. Perform the procedure twice each day. d. Perform the procedure prior to meals e. Administer a bronchodilator after the procedure. 87. A nurse on medical-surgical unit is performing medication reconciliation for newly admitted client. Which of the following actions should the nurse take? b. Compare the client’s list of home medications to the admission prescriptions written for the client. c. Compare a list of common medications to treat a condition to the actual prescriptions. d. Compare the prescription to the allergy history of the client.? e. Compare the medication label to the provider’s prescription on three occasions before administration. 88. A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? b. “The client exhibits impulsive behavior.” c. “The client might act seductively.” d. “The client is exceptionally clingy to others.” e. “The client is overly concerned about minor details”. 89. A nurse is teaching a client who is pregnant and has a new prescription for an iron supplement. Which of the following statement should the nurse include? b. “You should take this medication with a source of protein”. c. You should notify the provider if your stools turn black” d. Your urine will be an orange color while on this medication.” e. “You might become constipated while taking this medication.” 90. A nurse is caring for a client who has cancer of the throat findings is receiving and is receiving radiation therapy. The nurse should monitor for which of the following findings as an adverse effect of the radiation? b. Altered taste sensation c. Elevated platelet count d. Insomnia e. Excessive salvation 91. A nurse is caring for client who is febrile. To reduce the client’s fever, the nurse applies a cooling blanket. Which of the following findings indicates the client is having an adverse reaction to the cooling” b. Shivering c. Flushing d. Tachycardia e. Restlessness 92. A nurse is reviewing the laboratory report of a client who has been receiving lithium carbonate for the past 12 months. The nurse note lithium carbonate level of 0.8 mEQ/L. Which of the following orders from the provider should the nurse expect? a. Administer the medications. b. Discontinue the medication c. Withhold the next dose d. Increase the dosage 93. A nurse is preparing discharge information for a client who has type 2 diabetes mellitus. Which of the following information resources should the nurse provide to the client? a. Food label recommendations from the institute of Medicine b. Food exchange lists from meal planning from the American Diabetes Association. c. Diabetes medication information from the Physicians’ Desk Reference. d. Personal blogs about managing the adverse effects diabetes medications 94. A nurse is teaching a group of clients at community health fair about genetic risks for disease. Which of the following statements by a client indicates an understanding of the teaching? a. “If there is a genetic risk for future pregnancies. We can get treatment now to prevent the disease”. b. “There is no need to have genetic counseling if I know that I have family history of mental illness”. c. “My family has genetic risk for breast cancer, so I am considering a total mastectomy”. d. “Even if I have a genetic risk for a disease, the chance I will get the disease is probably low due to current medical treatments”. 95. A nurse in a surgical clinic is providing teaching to a client who is scheduled for a modified radical mastectormy. Which of the following statements by a client indicates an understanding of the teaching. a. “I can begin to drive 24 hours after surgery.” b. “ I will have my drains removed 1 hour prior to going home”. c. “I will completer my arm exercises for time a day.” d. “I can shower within 48 hours of my surgery.” 96. A nurse is assessing a client who ha uncomplicated vaginal birth 3 days ago. In which of the following locations should the nurse expect to palpate the client’s fundus? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) This has a picture 97. A nurse is caring for an infant who has carctation of the aorta. Which of the following should the nurse identify as an expected finding? a. Increased intracranial Pressure b. Frequent nosebleeds c. Weak femoral pulses d. Upper extremity hypotension 98. A nurse is providing teaching to a client who has heart failure and a new prescription furosemide. Which of the following statements should the nurse make? a. ‘Eat foods that are high in sodium”. b. “Taking furosemide can cause your potassium levels to be high.” c. Taking furosemide cause you to be overhydrated”. d. “Rise slowly when getting out of be.” 99. A nurse is assisting with food selection for client who follows kosher dietary traditions. Which of the following food choices should the nurse include on the client’s food try? a. Scrambled eggs and toast with milk b. Ham sandwich with milk c. Bacon and cheese quiche with milk d. Shrimp salad and tomato soup with milk 100. A nurse is caring for a client who has chronic kidney failure and serum potassium level of 6.8 mEq/L. Which of the following section should the nurse take first a. Request a prescription to obtain the client’s arterial blood gases b. Initiate continuous cardiac monitoring for the client c. Give sodium polystryne sulfonate to the client d. Prepare the client for hemodialysis 101. A nurse is reviewing the medication administration record of a client who has benign prostatic hyperplasia (BPH). The client asks the nurse about taking saw palmetto. The nurse should instruct the client that which of the following medications interacts adversely with saw palmetto? a. Clopidogrel b. Penicillin c. Zolpidem d. Ipratropium 102. A nurse is caring for client who is at 11 weeks of gestation. Which of the following immunizations should the nurse recommend? a. Influenza b. Varicella c. Human Papillomavirus d. Measles, mumps and rubella 103. A nurse is providing teaching to client who is on glucocorticoid therapy. Which of the following statements by the client indicates an understanding of the teaching? a. “I have my eyes examined annually.” b. “ I consistently take my medication between 8 and 9 each evening.” c. “I take a calcium and vitamin D supplement daily.” d. I limit my intake of foods with potassium 104. A nurse is providing teaching to client who is on glucocorticoid therapy. Which of the following statements by the client indicates an understanding of the teaching? a. “I have my eyes examined annually.” b. “I consistently take my medication be 8 and 9 each evening”. c. “I take a calcium and vitamin D Supplement daily.” d. “I limit my intake of foods with potassium.” 105. A nurse is caring for a client who has schizophrenia and is experiencing delusions. Which of the following actions should the nurse take? a. Encourage the client to rest quietly in bed twice per day b. Direct long conversations about the delusions toward reality-based topics. c. Avoid assessing client’s delusions d. Allow the client unlimited time to discuss the delusions when they occur. 106. A staff nurse is observing a newly licensed nurse suction a client’s tracheostomy. Which of the following actions by the newly licensed nurse a. Waits for 2 min between suctions b. Applies suction for 15 seconds c. Inserts the catheter without applying suction d. Encourage the client to cough during suctioning 112. A nurse is preparing to perform a heel stick on an infant. Which of the following actions should the nurse plan to take to reduce the infant’s pain during the procedure? a. Provide the infant with a bottle of water during the procedure b. Promote skin to kin contact with infant’s guardian during the procedure c. Apply lidocaine/prilocaine cream 15 min prior to the procedure d. Apply a cool cloth to the infant’s heel 5 min prior to the procedure. 113. A nurse is teaching participants at a community center about advance directives. Which of the following information should the nurse include in the teaching? a. A client must create a do-not-resuscitate order when completing advance directives. b. Advance directives cannot be changed once implemented. c. Assigning a health care surrogate requires legal consultation. d. A health care surrogate makes health care decisions when the client is no longer able 114. A nurse is teaching participants at a community center about advance directives. Which of the following information should the nurse include in the teaching? a. A client must create a do not resuscitate order when completing advance directives. b. Advance directives cannot be changed once implemented. c. Assigning a health care surrogate requires legal consultation d. A health care surrogate makes health care decisions when the client is no longer able 115. A nurse is assessing a newborn 2 hr following birth. Which of the following findings should the nurse expect? a. Temperature of 38.2” C(100.8F) b. Central Cyanosis c. Heart Rate 190/min d. Irregular respirations 116. A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan? a. Withdraw the client’s TV privileges if he does not attend group therapy b. Encourage the client to take frequent rest periods c. Encourage the client to spend time in the dayroom d. Place the client in seclusion when he exhibits sign of anxiety 117. A nurse is flushing a client’s intermittent infusion device. The client’s states. “Why do you have to do that if you are not giving me medicine?” Which of the following statements should the nurse make? a. “This prevents leakage of fluid and medication.” b. This clears blood from the tubing and the catheter.” c. ‘This helps to keep you hydrated. d. “This make sure it stays sterile.’ 118. A nurse is creating a plan of care for a newly admitted client who has obsessive- compulsive disorder. Which of the following interventions should the nurse include? a. Discourage the client from exploring irrational fears b. Give the client autonomy I scheduling activities c. Allow the client enough time to perform rituals d. Provide negative reinforcement for ritualistic behavior 119. A director of nursing in rehabilitation facility is planning to measure the quality of care provided. Which of the following audits should the Director plan to use after clients are discharged to gather information about quality of care? a. Prospective audit b. Structure audit c. Concurrent audit d. Outcome Audit 120. A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the following clients should the nurse see first? a. A client who has preeclampsia and reports a persistent headache b. A client who has pregestational diabetes mellitus and an HbA1c of 6.2% c. A client who is a 36 weeks of gestation and has biophysical profile score of 8 d. A client who is a 28 weeks of gestation and reports leucorrhea 121. A nurse on mental health unit is planning room assignments for four clients. Which of the following clients should the nurse assign to a room near the nurses’ station? a. A client who has a somatic symptom disorder and reports chronic pain b. A client who has bipolar disorder and impaired social interactions c. A client who has depressive disorder and reports feeling hopeless d. A client who has an anxiety disorder and is experiencing moderate anxiety 122. A nurse is caring for a 1-month old infant who has manifestation of severe dehydration and prescription for parenteral fluid therapy. The guide lines asks, “What are the indications that my baby needs an IV?” Which of the following responses should the nurse make? a. “Your baby needs an IV because she is breathing slower than normal.” b. “Your baby needs an IV because she is not producing tears.” c. “Your baby needs and IV because her fontanels are bulging.” d. “Your baby needs an IV v=because her heart rate is decreased.” 123. A nurse is assessing a client who is pregnant and has a new diagnosis for hyperemesis gravidarum. Which of the following findings should the nurse expect? a. Urine output 20 mL/hr b. Distended neck veins c. Elevated blood pressure d. Weight gain of 2 kg (4.4 Ib) 124. A nurse is caring for an infant who has respiratory syncytial virus. Which of the following intervention should the nurse take? b. Initiate neutropenic precautions* c. Administer palivizumab intravenously d. Suction nares prior to feeding e. Request a prescription for guaifenesin 126. A nurse is for a client who is wearing antiembolic stockings. Which of the following interventions should the nurse include in the plan of care? b. Apply the stockings after the client is in a chair c. Massage the clients legs once every 8 hr while the stockings are in place d. Determine if the stockings are binding e. Fold the top of the stockings over neatly 127. A nurse is teaching a client who is receiving radiation therapy about skin protection. Which of the following client statements indicates an understanding of the teaching? a. “I will expose the irradiated area of skin to the sun for no more than 30 min per day.” b. “I will apply my favorite unscented lotion to the irradiated area of skin twice each day.: c. “I will make sure I have sterile water to wash the irradiated area of skin.” d. “I will use my hand instead of a washcloth to wash the irradiated area of skin.” 128. A nurse is teaching a client who has heart failure about engaging in an exercise program. Which of the following statements by the client indicates an understanding of the teaching? a. “I will slow my walking pace of I experience chest pain.” b. “I will work to achieve 60 minutes of exercise each day.” c. “I will wait 30 min after eating before exercising.” d. “I will make sure I can still talk while exercising.” 129. A nurse is performing an abdominal assessment as part of a client's comprehensive physical examination. Which of the following is the final step the nurse should perform? a. Palpation b. Percussion c. Auscultation d. Inspection 130. A nurse is caring for a 1-day-old newborn that has jaundice and is receiving phototherapy. Which of the following actions should the nurse take? a. Apply lotion to the newborn every 4 hr b. Keep the infants head covered with a cup c. Give the infant 30 mL (1oz) of glucose water every 2 hr d. Ensure that the newborn wears a diaper 131. A nurse is caring for a client who received a transfusion of 250 mL of packed RBCs. The nurse should identify that which of the following findings indicates the client is responding positively to the transfusion? a. The clients lung sounds remain clear during the transfusion b. The clients hemoglobin level increases following the transfusion c. The client is afebrile during the transfusion d. The clients blood pressure increases to 140/85 mm Hg following the transfusion 132. A nurse in a PACU is caring for a client who is postoperative following a total knee arthroplasty using general anesthesia. Which of the following findings should the nurse report to the provider immediately? a. Urinary output is less than 15 mL/hr b. Systolic blood pressure is 20 mm Hg below baseline c. Nasal flaring is present with inspiratory stridor d. Pedal pulse is decreased in the affected extremity 133. A home health nurse is preparing to make an initial visit to a family following a referral from a local provider. Identify the sequence of steps the nurse should take when conducting a home visit. Put in order -Clarify the reason for the referral with the provider’s office -Record information about the home visit according to agency policy -Contact the family to determine availability and readiness to make an appointment -Identify family needs and interventions using the nursing process -Discuss plans for future visits with the family 134. A nurse is planning a community health program about Parkinson’s disease. Which of the following interventions should the nurse include as tertiary prevention strategy? a. Provide screenings for community members to identify early manifestations of Parkinson’s disease b. Provide daily exercise classes to improve ambulation for clients who have Parkinson’s disease c. Educate clients about common techniques used to diagnose Parkinson’s disease d. Educate clients who are at risk for Parkinson’s disease about maintaining a low-cholesterol diet 135. A nurse is providing discharge teaching to a client who has type 1 diabetes mellitus about preventing diabetic ketoacidosis when ill. Which of the following statements by the client indicated an understanding of the teaching? a. “I will not give myself insulin when I am sick.” b. “If I am sick, I will check my blood sugar twice a day.” c. “I will call my doctor if I am sick.” d. “I will decrease my fluid intake when I am sick.” 136. A nurse is caring for a client who has respiratory depression from an opioid administration. After administering naloxone to the client, which of the following findings should the nurse expect? a. Hyperglycemia b. Increased pain c. Hypoventilation d. Somnolence 137. A nurse is caring for a client who reports insomnia. Which of the following findings is priority for the nurse to report the provider? a. Snores loudly at night with morning headaches b. Awakens to urinate during the night c. Takes 15-min naps four to five times per day d. Seems depressed and irritable 138. A nurse is caring for a client who will undergo a procedure. The client states he does not want the provider to discuss the results with his partner. Which of the following is an appropriate response for the nurse to make? a. “Is there a reason you don’t want you partner to know about your procedure?” b. “Your partner can be a great source of support for you at this time.” c. “You have the right to decide who receives information.” d. “The provider will be tactful when talking to your partner.” 139. A newly licensed nurse is reviewing the role of a nurse in disaster planning. Which of the following is an activity a nurse should engage in to assist in disaster preparedness? a. Make quarantine preparations for those exposed to anthrax b. Vaccinate susceptible children and adults against smallpox c. Participate in community drills and mock events d. Assess types, levels, and scopes of disasters 140. A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect? a. Suspicious of others b. Preoccupied with aging c. Exhibits separation anxiety d. Ritualistic behavior* 141. A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? a. Bleeding gums b. Faintness upon rising c. Swelling of the face d. Urinary frequency 142. A nurse is planning care for a client who is receiving hemodialysis. Which of the following actions should the nurse include in the plan of care? a. Give an antibiotic 30 min before dialysis b. Withhold all medications until after dialysis c. Rehydrate with dextrose 5% in water for orthostatic hypotension d. Check the vascular access site for bleeding after dialysis 143. A nurse is caring for a client who has heart failure. For which of the following laboratory values should the nurse withhold the client morning dose of digoxin and contact the provider? a. Potassium 3.2 mEq/L b. Calcium 9.2 mg/L c. Magnesium 1.9 mEq/L d. Chloride 99 mEq/L 144. A nurse working in a health department is conducting a health screening for a group of farmworkers. Which of the following client statements indicates a possible health risk? a. “My home has running water and electricity.” b. “I wear a hat and long sleeves while I am working.” c. “I am currently sharing my home with two roommates.” d. “I eat vegetables directly from the field where I work.” 145. A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? a. A client who is receiving heparin for a DVT b. A client who is 1 day postoperative following a vertebroplasty c. A client who has COPD and a respiratory rate of 44/min d. A client who has cancer with a sealed implant for radiation therapy* 146. A nurse is assessing a client who is currently taking furosemide. Which of the following reports by the client indicates a manifestation of an adverse effect of this medication? a. Hearing loss b. Weight gain c. Increased urinary output d. Insomnia 147. A nurse is caring for a client who is in active labor and noted the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia? a. Maternal hypoglycemia* b. Maternal fever c. Chorioamnionitis d. Fetal anemia 148. A nurse is caring for a client who has a major burn injury. Which of the following actions is the nurse’s priority to prevent wound infection? a. Maintain consistent handwashing by the staff b. Place the client in protective isolation c. Apply topical antibiotics to the client’s wounds d. Use sterile dressings for wound care* 149. A nurse overhears two assistive personnel (AP) discussing care for a client while in the elevator. Which of the following actions should the nurse take? a. File a complaint with the facility’s ethics committee b. Notify the client’s provider about the incident c. Report the incident to the AP’s charge nurse * d. Contact the client’s family about the incident 150. A nurse is preparing to obtain a client’s signature on an informed consent form. Which of the following actions should the nurse take first? a. Ask the client to explain his understanding of the procedure* b. Inform the client of his right to change his mind c. Witness the client signing the informed consent form d. Notify the provider if the client has questions about the procedure 151. A nurse is reviewing laboratory findings for a client who is receiving total parental nutrition. For which of the following findings should the nurse notify the provider? a. Potassium 3.8 mEq/L b. WBC count 6,000/mm3 c. Random glucose 120 mg/dL d. Sodium 125 mEq/L 152. A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider? a. Temperature 37.4 C (99 F) b. Contractions lasting 80 second * c. FHR baseline 170/min d. Early decelerations in the FHR 153. A nurse is assessing a client coccyx area for a pressure ulcer. The nurse notes that superficial subcutaneous fat is visible and tunneling is present. Which of the following pressure ulcer stages should the nurse document? a. Stage IV b. Unstageable c. Stage III d. Stage II 154. A nurse in a mental health facility is caring for a client who is experiencing a panic level of anxiety. Which of the following actions should the nurse take? a. Use short sentences when communicating with the client b. Encourage the client to talk about his feelings c. Tell the client to sit alone in a private place and reflect on the situation d. Have the client journal about what is happening to him 155. A nurse in an emergency department is caring for a client who has a closed head injury. Which of the following actions should the nurse take first? a. Prepare the client for an MRI of the brain b. Administer mannitol IV bolus to the client c. Determine the clients Glasgow Coma Scale score* d. Insert an indwelling urinary catheter for the client 156. A nurse in an intensive care unit is assessing a client who has heart failure and has been receiving metoprolol for 3 days. Which of the following indicates the treatment has been effective? a. Decreased urinary output b. Increased blood pressure c. Increased heart rate d. Decreased edema 157. A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include? a. “This type of seizure can be mistaken for daydreaming.” b. “This type of seizure lasts 30 to 60 seconds.” c. “The child usually has an aura prior to onset.” d. “This type of seizure has a gradual onset.” 158. A nurse is reviewing home recommendations with a client who is postoperative following knee surgery. Which of the following recommendations should the nurse make? a. Place a handrail in the entryway of the house b. Wear slippers with cloth soles c. Ensure that all area rugs are rubber-based d. Place a towel on the floor outside of the shower 159. A nurse is caring for a client who is 12 hr postoperative following a transurethral resection of the prostate. Which of the following findings should the nurse report to the provider? a. Urgency to void b. Report of pain level of 5 on a scale of 0 to 10 c. Passage of small clots d. Burgundy-colored urine 160. A nurse is assessing a school-age child who has a urinary tract infection. Which of the following findings should the nurse expect? a. Enuresis b. Periorbital edema c. Decreased frequency of urination d. Diarrhea [Show More]

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