ATI COMPREHENSIVE PREDICTOR

2019 A / 150 QUESTIONS AND

ANSWERS WITH RATIONALES
GRADED A+

A nurse is caring for a client who states, "My boss accused me of

stealing yesterday. I was so angry I went to the gym and worked out."
The nurse should recognize the client is demonstrating which of the
following defense mechanisms? - ANSWER- Sublimation

Rationale: The client is exhibiting behaviors consistent with

sublimation, which is displayed when a client substitutes socially
unacceptable behavior for acceptable behavior.
A nurse is caring for a client who has generalized anxiety disorder and is
to begin taking alprazolam. Which of the following actions should the
nurse take? - ANSWER- Initiate fall precautions for the client

Rationale: The nurse should initiate fall precautions for a client who
has a new prescription for alprazolam because common adverse
effects associated with this medication are orthostatic hypotension,
dizziness, confusion, and lethargy.

A nurse on a med surg unit is caring for a client prior to a surgical

procedure. Which of the following findings should indicate to the nurse
that the client has the ability to sign the informed consent? - ANSWER-
The client is able to accurately describe the upcoming procedure

Rationale: The ability of the client to accurately describe the

upcoming procedure indicates that the provider adequately
informed the client and that the client is able to sign the informed
consent

An assistive personnel (AP) and a nurse are turning a client onto the
right side. Which of the following actions by the AP requires the nurse to
intervene? - ANSWER- Places a pillow under the client's right arm.

Rationale: The AP should place a pillow under the client's left arm
to prevent internal rotation of the left shoulder.
A nurse is providing dietary teaching to the parents of a 6-month-old
infant. Which of the following instructions should the nurse include? -
ANSWER- Introduce new foods one at a time over 5 to 7 days.

A nurse is caring for a client who has MRSA in an abdominal wound.

Which of the following precautions should the nurse implement? -
ANSWER- Contact

Rationale: The nurse should implement contact precautions for a

client who has an infection spread by direct contact, such as MRSA.

A nurse is caring for a client who is 4 hr postpartum and has a boggy

uterus with heavy lochia. Which of the following actions should the
nurse take first - ANSWER- Massage the uterus to expel clots

Rationale: Using the EBP approach to client care, the nurse should
identify that the priority action is massaging the client's uterus.
Uterine massage will expel clots and increase uterine firmness,
resulting in decreased bleeding.

A nurse is providing discharge teaching to a new parent about car seat

safety. Which of the following statements should the nurse include in the
teaching? - ANSWER- "Secure the retainer clip at the level of your
baby's armpits"

A nurse is providing discharge teaching to a client who has colorectal

cancer and a new colostomy. The client states, "I'm worried about being
discharged because I live alone, and my insurance doesn't cover ostomy
supplies. "Which of the following actions should the nurse take? (SATA)
- ANSWER- -Refer the client to a community based social workers
-Initiate a consult with a home health care provider
-Give the client information about local support groups

Rationale:
-A social worker is necessary to help a client with self-care, as well as
assist in locating agencies who can help the client face challenges
with self-care and paying for necessary ostomy supplies
-A home health nurse can assist the client in learning to care for the
colostomy as well as provide medication management and emotional
support
-A client who has cancer and a new colostomy can get help with
coping from a support group and possibly receive assistance
obtaining supplies from local agencies

A nurse manager is reviewing unit records and discovers that client falls
occur most frequently during the hours of 0530 and 0730. Which of the
following actions should the nurse take when conducting a root cause
analysis? - ANSWER- Investigate environmental factors that might be
contributing to client injury during these hours.

Rationale: When conducting a root cause analysis, the nurse should

look at the factors that could possibly lead to the clients' falls. This
can include environmental factors that might be causing the
problem.
A nurse is caring for a client who has terminal illness and requests
lifesaving measures if a cardiac arrest occurs. Which of the following
statements should the nurse make? - ANSWER- "I will provide you with
information about medical treatment to include in your living will"

Rationale: The nurses' responsibility is to provide the client with

information about specific instructions for addressing medical
treatment in a living will. The nurse should assist the client while
they are able to make decisions for themself by providing
information about what end-of-life preferences to document.

A nurse is assessing a client who has delirium. Which of the following

manifestations should the nurse expect? - ANSWER- Rapid speech

Rationale: Clients who have delirium exhibit rapid, inappropriate,

incoherent, and rambling speech patterns

A night shift nurse is giving a change of shift report to the day shift
nurse on a client who is ready for discharge. Which of the following
information is the priority for the nurse to communicate to the oncoming
nurse? - ANSWER- The client needs assistance when transferring from
the bed to a wheelchair.

Rationale: The greatest risk to this client is injury due to a fall.

Therefore, the priority information for the nurse to communicate is
that the client requires assistance during transfers.
A nurse is assessing a client during the immediate postpartum period.
Which of the following findings requires immediate intervention by the
nurse? - ANSWER- Boggy uterus

Rationale: When using urgent vs. nonurgent approach to client care, the
nurse should determine that the priority finding is a boggy uterus, which
can indicate uterine hemorrhage. The nurse should immediately
intervene to stimulate uterine contractions and prevent blood loss. If the
uterus becomes relaxed during the postpartum period, the client will
rapidly lose blood because no permanent thrombi have formed at the
placenta.

A nurse in an emergency department is preparing to discharge a client

who has experienced intimate partner violence. Which of the following
actions should the nurse take first? - ANSWER- Develop a safety plan
with the client

Rationale: The greatest risk to this client is injury from violence.

Therefore, the first action the nurse should take is to develop a safety
plan with the client.

A client is receiving lorazepam IV for panic attacks and develops a

respiratory rate of 6/min and a blood pressure of 90/44 mm Hg. Which
of the following medications should the nurse anticipate administering. -
ANSWER- Flumazenil
Rationale: The nurse should anticipate administering flumazenil, a
competitive benzodiazepine receptor antagonist, to reverse the sedative
effects of lorazepam. In addition, the nurse should continue to support
the client's respirations with a bag valve mask.

A home health nurse is planning care for an older adult client who has
impaired vision. Which of the following interventions should the nurse
include in the plant of care to prevent injury in the home? - ANSWER-
Mark the edges of the stairs for contrast

Rationale: Marking the edges of stairs with paint or colored tape for
contrast can help older adult clients who have impaired vision prevent
injury by decreasing the risk of falls.

A nurse manager is planning to make changes to the current scheduling

system on the unit. To facilitate the staff's acceptance of this change,
which of the following actions should the nurse manager take first? -
ANSWER- Provide information about scheduling issues to the staff.

Rationale: The first stage of the change process is the unfreezing stage,
when the nurse should inform the staff about the current staffing issues.
This can increase their understanding of why changes are necessary.

A nurse is teaching a group of guardians about child safety measures.

Which of the following statements by guardian indicates an
understanding of the teaching? - ANSWER- "I should have my child
avoid sun exposure between 10 am and 2 pm"
Rationale: To prevent sunburns, guardians should apply sunscreen, dress
their child in protective clothing, and avoid sun exposure between 1000
and 1400.

An RN is planning care for a group of clients and is working with a

licensed practical nurse (LPN) and an assistive personnel (AP). Which
of the following tasks should the RN delegate to the LPN? - ANSWER-
Insertion of a nasogastric tube

Rationale: The nurse should delegate the insertion of a nasogastric tube

to the LPN because this task is within the LPN's scope of practice.

A nurse is assessing a newborn who is 2 hr old. Which of the following

findings should the nurse report to the provider? - ANSWER- Axillary
temperature 36.2 C (97.2 F)

Rationale: The expected reference range for the axillary temperature of

newborn is between 36.5 C to 37.5 C (97.7 F to 99.5 F). An axillary
temperature of 36.2 C (97.2 F) or below in a newborn who is 2 hr old
indicates cold stress and should be reported to the provider.

A nurse is caring for a newborn whose parent asks why the baby is
receiving vitamin K. The nurse should explain to the parent that the
newborn should receive vitamin K to prevent which of the following? -
ANSWER- Bleeding
The nurse should explain to the parent that newborns are deficient in
vitamin K and should receive it following birth because this deficiency
can lead to bleeding.

A nurse is caring for a client who requires physical therapy following

discharge. Which of the following actions should the nurse take? -
ANSWER- Involve the client in selection of a physical therapy provider/

Rationale: The nurse should involve the client in the referral process,
including selection of the physical therapist and the location.

A nurse in an emergency department is assessing a client who reports

taking MDMA. Which of the following should the nurse expect? -
ANSWER- Diaphoresis

Rationale: Diaphoresis is an expected finding of MDMA use.

Additionally, the client might experience increased tactile sensitivity,
lowered inhibition, chills, muscle cramping, teeth clenching, and mild
hallucinogenic effects.

A nurse is caring for a client who vomits on a reusable BP cuff. Which

of the following actions should the nurse take? - ANSWER- Place the
BP cuff in a labeled bag to send it for decontamination.

Rationale: The nurse should place the BP cuff in a labeled bag before
removing it from the client's room and sending it to the proper facility
location for decontamination.
A nurse is reviewing the medical record of a client who has
schizophrenia and is to start taking clozapine. Which of the following
findings should the nurse identify as a contraindication for the client to
receive clozapine? - ANSWER- WBC count 2,800/mm3

Rationale: Clozapine can cause agranulocytosis, which can be life-

threatening. Therefore, a WBC count of less than 3,000/mm3 is a
contraindication for the client to receive clozapine. The nurse should
withhold the medication and notify the provider of the client's WBC
count.

A nurse is providing teaching to an adolescent following insertion of a

tunneled central venous catheter without a pressure sensitive valve.
Which of the following information should the nurse include in the
teaching? - ANSWER- "You should keep the catheter clamped when not
in use"

Rationale: The adolescent should keep the catheter clamped to prevent

blood backflow. Not all tunneled catheters have a pressure-sensitive
valve that prevents blood reflux.

A nurse is conducting visual acuity testing when using the Snellen letter
chart for a school age child who has eyeglasses. Which of the following
instructions should the nurse give to the child? - ANSWER- "You should
keep both eyes open during the testing"
Rationale: The nurse should instruct the child to keep both eyes open
during visual acuity testing.

When caring for a child, a nurse plans to use non-pharmacological

interventions to enhance the effectiveness of pain medication. Which of
the following strategies incorporates visualization techniques to help
decrease the child's discomfort? - ANSWER- Blowing bubbles with
liquid soap to "blow the hurt away"

Rationale: Having the child blow bubbles is a visualization technique

that can help to decrease the child's discomfort. The child can visualize
the pain as the bubble that they blow away from themself and into the
air.

A nurse is preparing to administer heparin 5,000 units SQ. Available is

heparin injection 10,000 units/mL. How many mL should the nurse
administer per dose? - ANSWER- 0.5 mL

5,000 units/ 10,000 units = 0.5 mL

A charge nurse is observing a newly licensed nurse performing a

physical assessment on a client. Which of the following actions by the
nurse indicates that the charge nurse should intervene? - ANSWER- The
newly licensed nurse writes detailed notes while performing the head-to-
toe assessment.
Rationale: The newly licensed nurse should record brief notes during the
assessment to avoid delays and write more detailed notes after
completing the assessment.

A nurse is assessing a client who has schizophrenia. The nurse should

identify the following alteration in speech as which of the following?
(Audio) - ANSWER- Clang association

Rationale: Clang association is an alteration in speech in which the client

uses words based on their sound, rather than their meaning. Clients who
have neurological disorders can also have this alteration in speech.

A nurse is assessing a school age-child who has cystic fibrosis. Which of

the following findings is the priority for the nurse to report to the
provider? - ANSWER- Hemoptysis 275 mL/24 hr

Rationale: Hemoptysis greater than 250 mL/24 hr indicates that this

child is at greatest risk for hemorrhage. Therefore, this is the priority
finding for the nurse to report.
Fever

A nurse is caring for a client who ha bipolar disorder. The nurse

observes that the client is becoming increasingly restless. The client is
pacing the unit and speaking rapidly, frequently using profanities and
sexual references. Which of the following actions should the nurse take
first? - ANSWER- Move the client to a quiet place away from others.
Rationale: The client's behavior indicates the greatest risk is injury to
others. Therefore, the first action the nurse should take is to prevent
harm to other clients by moving the client to a quiet place away from
others.

A nurse is providing colostomy care for a client using a two-piece

pouching system. Which of the following actions should the nurse take?
- ANSWER- Place the skin barrier over the stoma and hold it for 30
seconds.

Rationale: The nurse should activate the adhesive in the skin barrier by
holding it in place over the stoma for 30 seconds.

A nurse is teaching the parent of a school-age about administering ear

drops. Which of the following response by the parent indicates an
understanding of the teaching? - ANSWER- "I should pull the top of the
ear upward and back while instilling the medication."

Rationale: The nurse should instruct the parent to pull the pinna upward
and back in children older than 3 years of age to straighten the ear canal
and allow the medication to reach the entire canal. For children younger
than 3 years of age, the parent should gently pull the pinna downward
and back.

A nurse is assessing a client who is 2 hr postoperative following a

cardiac catheterization. Which of the following information should the
nurse report to the provider? - ANSWER- Neurologic status
Rationale: This client is experiencing slurred speech and extremity
weakness, which are indications of a stroke, a potential complication of
cardiac catheterization. The nurse should report these findings to the
provider.

A nurse is caring for a client who is receiving total parenteral nutrition

(TPN) solution by continuous IV infusion at 60 mL/hr. The nurse
discovers the infusion pump has stopped working. Which of the
following actions should the nurse take while waiting for a new infusion
pump? - ANSWER- Provide dextrose 10% in water solution using
manual drip tubing at 60 mL/hr.

Rationale: The nurse should use an infusion pump when administering

TPN solution to ensure accurate dosage and should taper the infusion
rate before discontinuing the solution to prevent hypoglycemia. If the
nurse is unable to continue the TPN infusion by infusion pump, the
nurse should use manual drip tubing to infuse dextrose 10% in water at
the same rate as the TPN solution.

A nurse is caring for a client who has an STI that must be reported to the
state health department. Which of the following actions should the nurse
take? - ANSWER- Explain to the client why this information will be
shared.

Rationale: It is the responsibility of the nurse to advocate for the client,

provide confidential information, and explain legal requirements.
Reporting communicable disease occurrences helps with identifying
outbreaks and overall disease trends.
A nurse is caring for a group of clients. For which of the following
events should the nurse complete an incident report? - ANSWER- A
client's IV pump delivers an inadequate dose of medication.

Rationale: The nurse should complete an incident report to record

occurrences which resulted in a medication error, such as a failure of the
IV pump, as part of the quality improvement process. Other situations
requiring an incident report include significant complaints about care
quality and visitor or client injury.

A nurse is caring for a client who has hypertension and is taking

captopril. Which of the following tasks should the nurse delegate to an
assistive personnel (AP)? - ANSWER- Obtain the client's blood pressure
before the nurse administers medication.

Rationale: The nurse can delegate obtaining blood pressure before and
after medication administration because this task is within the range of
function for an AP.

A nurse is assessing a client who is receiving a blood transfusion. Which

of the following findings should indicate to the nurse that the client is
having a hemolytic transfusion reaction? - ANSWER- Low back pain

Rationale: The nurse should expect low back pain in a client who is
having a hemolytic transfusion reaction.
A nurse is caring for a toddler who has infectious gastroenteritis. Which
of the following actions should the nurse take? - ANSWER- Initiate oral
rehydration therapy for the toddler.

Rationale: Infectious gastroenteritis can lead to dehydration. The nurse

should treat the toddler with oral rehydration therapy to replace fluids
lost by diarrhea. Soft or pureed foods can be given along with the oral
rehydration therapy. After adequate rehydration has occurred, a regular
diet can be resumed.

A nurse is administering medications to a client who has percutaneous

gastrostomy tube for enteral feedings. Which of the following actions
should the nurse take to prevent clogging of. the tube? - ANSWER-
Flush the client's gastrostomy tube with 30 mL of water before
administering the medication.

Rationale: The nurse should flush the gastrotomy tube with at least 30
mL of water before and after medication administration to clear the tube
of any residuals and to ensure patency.

A nurse is teaching home wound care to the family of a child who has a
large wound. Which of the following interventions should the nurse
recommend? - ANSWER- Double-bag soiled dressings in plastic bags
for disposal.

Rationale: The client should double-bag soiled dressings in plastic bags

to prevent the spread of micro-organisms to other household members.
A nurse is teaching the parents of a toddler about snacks. Which of the
following foods should the nurse recommend? - ANSWER- Diced
steamed carrots

Rationale: Diced steamed carrots are a safe food choice for toddlers
because they are soft and do not present a choking hazard.

A nurse is assessing a preschooler who has cystic fibrosis and has been
receiving oxygen therapy for the past 36 hr. Which of the following
findings should the nurse identify is an indication that the client has
developed oxygen toxicity? - ANSWER- Substernal pain

Rationale: The nurse should identify substernal pain as a manifestation

of oxygen toxicity due to the increased work of breathing, such as in a
preschooler who has cystic fibrosis.

A charge nurse is observing a newly licensed nurse administer enteral

feedings via NG tube. Which of the following actions by the newly
licensed nurse indicates an understanding of the procedure? - ANSWER-
Keeps the head of the bed elevated to 45° for 1 hr after feedings

Rationale: The nurse should keep the client's head elevated to 30° to 45°
for 1 to 2 hr after feedings to decrease the risk for aspiration.

A nurse is assessing a client who has Raynaud's disease. Which of the

following findings should the nurse expect? - ANSWER- Blanching of
the fingers and toes
Rationale: A client who has Raynaud's disease can have blanching of the
fingers and toes in response to exposure to cold or emotional stress.
Pallor develops first, then cyanosis, followed by redness or heat as the
vessels reperfuse, before the skin returns to the client's baseline tone

A nurse is talking with the partner of a client who attempted suicide.

Which of the following statements by the client's partner should the
nurse identify as the priority? - ANSWER- "My husband doesn't know
that I've already moved out of the house and filed for a divorce."

Rationale: A lack of social support and isolation indicates the client is at

greatest risk for another suicide attempt. Therefore, this is the priority
concern that the nurse should report to the provider.

A nurse in a clinic receives a call from a guardian whose child has

varicella. The guardian asks when the child can return to school. Which
of the following responses should the nurse make? - ANSWER- "When
crusts have formed on every lesion."

Rationale: The child should return to school once all the lesions have
crusted over. Varicella is no longer contagious after crusts have formed
on all lesions.

A nurse is caring for a toddler who is admitted to the pediatric unit for
surgery. Which of the following should the nurse include in the toddler's
plan of care? - ANSWER- Encourage the parents to bring toys from
home.
Rationale: To help decrease the toddler's anxiety, the nurse should
encourage the family to bring familiar objects from home, such as toys,
blankets, and feeding utensils.

A nurse is caring for an older adult client in the PACU following general
anesthesia. Which of the following findings should the nurse report to
the provider? - ANSWER- Audible stridor

Rationale: Audible stridor, or a high-pitched sound heard in the client's

airway indicates edema, laryngeal spasm, secretions, or some type of
airway obstruction that could become life-threatening. The nurse should
report this finding to the provider.

A nurse is preparing to insert an indwelling urinary catheter for a client.

The nurse should assess the client for which of the following conditions
prior to starting the procedure? - ANSWER- Latex allergy

Rationale: The nurse should assess the client for a latex allergy prior to
the insertion of an indwelling urinary catheter due to the risk of an
allergic reaction

A home health nurse is providing teaching about infection prevention to

a client who has cancer and is receiving chemotherapy. Which of the
following statements by the client indicates an understanding of the
teaching? - ANSWER- "I will walk for short distances throughout the
day."
Rationale: The client should ambulate for short distances as tolerated
throughout the day. This will help to reduce pulmonary stasis and
prevent the development of respiratory infections

A nurse is caring for a client who has end-stage Alzheimer's disease. The
adult child of the client says to the nurse, "I don't know why I bother to
visit my mother anymore." Which of the following responses should the
nurse make? - ANSWER- "It seems like you feel your visits are a waste
of time."

Rationale: The nurse is using a clarifying technique that facilitates the

nurse's understanding of the adult child's feelings

A charge nurse assigns a newly licensed nurse to care for a client who
has a chest tube. The nurse expresses concern about having limited
experience with monitoring chest tube drainage. Which of the following
actions should the charge nurse take first to provide teaching about chest
tubes? - ANSWER- Ask the nurse about their knowledge of the
procedure.

Rationale: The first action the charge nurse should take using the nursing
process is to assess the newly licensed nurse's knowledge about the
procedure. By assessing the nurse's knowledge, the charge nurse can
identify the nurse's learning needs.

A nurse is caring for an adolescent client who has a new diagnosis of

terminal cancer. When discussing the client's prognosis with the parents,
the nurse should recognize which of the following responses by the
parents as an example of rationalization? - ANSWER- "Maybe this is
better for our child because we don't want any suffering through
chemotherapy treatments."

Rationale: By justifying the adolescent's prognosis by searching for a

more personally acceptable explanation for the impending loss, the
parent is using the defense mechanism of rationalization.

A nurse is caring for a client who is at 28 weeks of gestation. The client

asks the nurse to explain what causes the nurse to explain what causes
her to have constipation. Which of the following responses should the
nurse make? - ANSWER- "The enlarged uterus compresses the
intestines and causes constipation."

Rationale: During the second and third trimesters, the size and weight of
the growing uterus cause both displacement and compression of the
intestines. These changes cause a decrease in motility, leading to
constipation.

A nurse is teaching a client who has opioid use disorder about

methadone. Which of the following information should the nurse include
in the teaching? - ANSWER- "Sedation is a common adverse effect of
this medication."

Rationale: Sedation and drowsiness are common adverse effects of

methadone. Sedation most frequently occurs at the beginning of
treatment or during dosage increases.
A community health nurse is reviewing the medical records of four
newly diagnosed clients. The nurse should identify which of the
following clients as having a nationally notifiable infectious condition? -
ANSWER- An adolescent client who has foodborne botulism

Rationale: The nurse should report botulism to the CDC because this
information is necessary for the prevention and control of this disease.
Clients who ingest the botulism toxin can develop dysphasia, drooping
eyelids, and vision changes, and in 12 to 36 hr can develop neurologic
symptoms such as symmetric, flaccid paralysis and cranial nerve
impairment.

A nurse is assessing a client who is experiencing autonomic dysreflexia.

which of the following findings should the nurse expect? (SATA) -
ANSWER- -Facial flushing is correct. The nurse should expect a client
who has autonomic dysreflexia to have facial flushing. Flushing occurs
from the point of the lesion upward.
-Nasal congestion is correct. The nurse should expect a client who has
autonomic dysreflexia to have nasal congestion.
-Headache is correct. The nurse should expect a client who has
autonomic dysreflexia to have a severe headache.

A nurse is caring for a client who is 12 hr postoperative, is receiving

PCA for pain control, and requires a blood pressure check every 10 min.
Which of the following staff members should the nurse assign to collect
this information? - ANSWER- An assistive personnel (AP) who is
assisting a client to return to bed
Rationale: Performing a blood pressure check is within the range of
function of an AP, and the AP should be available to obtain a blood
pressure within the specified time.

A charge nurse observes a staff nurse document a dressing change in a

client's chart that was not performed. Which of the following actions
should the charge nurse take first? - ANSWER- Gather more
information about the staff nurse's actions.

Rationale: The first action the nurse should take when using the nursing
process is to assess the reasons for the staff nurse's negligent actions.
Therefore, the charge nurse should gather additional information and
discuss the issue with the staff nurse before deciding on the next course
of action.

A home health nurse is providing teaching to a client who has hepatitis

A. Which of the following instructions should the nurse include? -
ANSWER- Use hydrogen peroxide to clean kitchen surfaces.

Rationale: The client should clean kitchen surfaces with hydrogen

peroxide to kill the virus and prevent transmission.

A nurse manager is on a planning committee to develop an emergency

preparedness plan. The nurse should recommend that which of the
following actions takes place first when implementing an emergency
preparedness plan? - ANSWER- Notify the incident commander.
Rationale: The first action to take when implementing an emergency
preparedness plan is to notify the incident commander to initiate the
command hierarchy and maintain order.

A nurse is performing an admission assessment of a preschooler who is

in the acute phase of Kawasaki disease. Which of the following findings
should the nurse expect? - ANSWER- Fever unresponsive to antipyretics

Rationale: The nurse should expect a child who has acute Kawasaki
disease to have a high fever that is unresponsive to antibiotics or
antipyretics.

A nurse is caring for an older adult client. Which of the following

findings should the nurse recognize as a physiological change associated
with aging? - ANSWER- Decreased lung expansion

Rationale: Older adult clients are more likely to have decreased lung
expansion due to decreased mobility of the ribs.

A nurse is providing teaching about improving nutrition for a client who

has multiple sclerosis. Which of the following instructions should the
nurse include? (SATA) - ANSWER- -"A speech pathologist will be
performing a swallowing study for you." is correct. The nurse should
instruct the client that a swallowing study will be performed to
determine the client's risk for aspiration due to difficulty swallowing,
which is a manifestation of multiple sclerosis.
-"You should rest before eating a meal." is correct. The nurse should
encourage the client to rest before each meal. Clients who have multiple
sclerosis often report weakness and are easily fatigued.
-"Thicken your beverages before drinking." is correct. The nurse should
instruct the client that liquids should be thickened to reduce the risk of
aspiration due to difficulty swallowing, which is a manifestation of
multiple sclerosis.

A nurse is assessing a client who has obstructive sleep apnea. For which
of the following complications should the nurse monitor? - ANSWER-
Hypertension

Rationale: The nurse should assess the client for hypertension, a

complication of obstructive sleep apnea from hypoxia. Other
complications include heart failure and cardiac dysrhythmias.

A charge nurse is teaching a newly licensed nurse how to identify true

labor. Which of the following should the nurse include in the teaching? -
ANSWER- The cervix transitions to an anterior position.

Rationale: In true labor, the cervix transitions to an anterior position and

begins to dilate in preparation for birth.

A nurse is planning care for a client who is receiving hemodialysis via

an established arteriovenous (AV) fistula in the right arm. Which of the
following interventions should the nurse include in the client's plan of
care? - ANSWER- Auscultate the affected extremity for a bruit.
Rationale: The nurse should auscultate the AV fistula every 4 hr to
ensure a bruit is present, which indicates patency.

A nurse is planning teaching about allowable foods for a client who has
a history of uric acid-based urinary calculi formation. Which of the
following foods should the nurse include in the teaching? - ANSWER-
Oranges

Rationale: A client who is prone to uric acid calculi formation can eat
citrus fruits.

A nurse is assessing a client who has multiple sclerosis. Which of the

following manifestations should the nurse expect? - ANSWER-
Nystagmus

Rationale: Nystagmus is involuntary eye movements and muscle

spasticity, which are manifestations of multiple sclerosis.

A nurse is preparing to administer a long-acting insulin to a client who

has diabetes mellitus. Which of the following actions should the nurse
plan to take first? - ANSWER- Check the insulin dose with another
licensed nurse.

Rationale: The greatest risk to the client is injury due to a medication

error. Therefore, the priority action is for the nurse to validate the correct
dose of insulin with another licensed nurse prior to administration.
Insulin is a high-alert medication and incorrect dosages can be fatal for
the client

A nurse is caring for a client who is in the manic phase of bipolar

disorder. Which of the following manifestations should the nurse
expect? - ANSWER- Grandiose delusions

Rationale: Clients who are in the manic phase of bipolar disorder

typically exhibit behaviors that appear to be euphoric. Clients can also
have abrupt mood changes, expansiveness, unlimited energy, poor
impulse control, and grandiose delusions.

A case manager is reviewing the medical records of several clients. For

which of the following clients should the nurse request an
interprofessional care conference? - ANSWER- A client who has
diabetes mellitus and has had repeated hospitalizations for diabetic
ketoacidosis

Rationale: A client who is having repeated episodes of a life-threatening

complication requires an interprofessional care conference so team
members can address the client's needs to provide care and support.

A nurse working on a medical-surgical unit receives a telephone call

requesting the status of a client from an individual who identifies
themself as the client's parent. Which of the following actions should the
nurse take? - ANSWER- Ask the caller for verification of their identity.
Rationale: According to HIPAA, if someone requests information about
a client it is the nurse's duty to protect that information. Therefore, the
nurse should inform the caller that nurses cannot release any client
information over the phone without the permission of the client. The
nurse should ask for verification of the caller's identity to determine if
they have been authorized by the client to receive information.

A nurse is caring for a client who is at 37 weeks of gestation and is

experiencing abruptio placentae. Which of the following findings should
the nurse expect? - ANSWER- Persistent uterine contractions

Rationale: The nurse should expect a client who has abruptio placentae
to experience persistent uterine contractions, board-like abdomen, and
dark red vaginal bleeding.

A nurse is providing discharge instructions to a client following a total

hip arthroplasty. Which of the following instructions should the nurse
include? - ANSWER- Install a raised toilet seat at home.

Rationale: The client should use a raised toilet seat at home to minimize
hip flexion and prevent hip dislocation.

A nurse is preparing to administer enoxaparin to a client. Identify the

area the nurse should use to administer the injection. - ANSWER- A is
correct. The nurse should recognize that enoxaparin is administered into
the subcutaneous tissue, specifically in the periumbilical area
A nurse in an outpatient mental health clinic is working with a client
who has post-traumatic stress disorder (PTSD) and asks the nurse to
recommend a nonpharmacological therapy to use to provide relief of the
manifestations. Which of the following complementary therapies should
the nurse teach the client to use to help alleviate the distress? -
ANSWER- Guided imagery

Rationale: Helping clients imagine themselves as strong and capable and

in settings that are positive and therapeutic can assist clients who have
PTSD by relieving anxiety and pain.

A nurse is caring for four clients. Which of the following clients should
the nurse assign to an assistive personnel (AP) to assist with meals? -
ANSWER- A client who has Alzheimer's disease and is demonstrating
aphasia

Rationale: Aphasia impairs the client's ability to communicate but does

not interfere with nutritional intake or place the client at an increased
risk for aspiration while eating. Therefore, assisting the client with meals
is within the AP's range of function.

A community health nurse is assisting with the development of a disaster

management plan. The nurse should include which of the following
nursing responsibilities in the disaster response stage of the plan? -
ANSWER- Performing a rapid needs assessment

Rationale: Disaster management includes prevention, preparedness,

response, and recovery stages. The nurse should perform a rapid needs
assessment during the response phase of the disaster cycle. A rapid needs
assessment allows the nurse to identify the severity of the incident, the
health needs of the community, and the priority actions needed during
the response stage.

A community health nurse is preparing a health education program for a

local rural community. Which of the following actions should the nurse
plan to take first? - ANSWER- Identify health-related issues within the
community.

Rationale: The first action the nurse should take when using the nursing
process is to assess the clients living in the community to identify the
prevalent health problems.

A charge nurse is planning an educational session for staff nurses about

working with parents whose terminally ill children are candidates for
donating their organs. Which of the following information should the
nurse plan to include? - ANSWER- The family can have the child in an
open casket without fearing that the organ donation might disfigure the
child's body.

Rationale: Removal of organs does not damage or violate the child's

body in a way that would prevent an open casket funeral.

A nurse is assessing a client who has schizophrenia and is taking

chlorpromazine. Which of the following findings is the priority for the
nurse to report the provider? - ANSWER- Temperature 39.4° C (102.9°
F)
Rationale: The greatest risk to this client is injury from neuroleptic
malignant syndrome, a potentially life-threatening adverse effect of
chlorpromazine that can cause the client to have a high temperature,
dysrhythmia, decreased level of consciousness, and a labile blood
pressure. Therefore, the priority finding for the nurse report to the
provider is a fever.

A nurse is providing discharge teaching to a client following a cataract

extraction. Which of the following statements by the client indicates an
understanding of the teaching? - ANSWER- "I will bend at my knees
when picking an object up off the floor."

Rationale: The client should avoid bending at the waist, because this
movement increases intraocular pressure. The nurse should instruct the
client to bend at the knees when picking up an object.

A nurse is assessing a client who has macular degeneration. Which of

the following findings should the nurse expect? - ANSWER- Decreased
central vision

Rationale: The nurse should expect a client who has macular

degeneration to have a decrease or loss of central vision due to bleeding
into the macula or yellow spots under the retina.

A nurse is planning care for a client who is receiving heparin to treat a

deep-vein-thrombosis of the left lower leg. Which of the following
interventions should the nurse include in the plan of care? - ANSWER-
Elevate the affected leg.

Rationale: The nurse should elevate the client's affected extremity to

reduce edema and decrease the risk of chronic venous insufficiency.

A nurse is providing teaching to a client about newborn safety. Which of

the following statements should the nurse include in the teaching? -
ANSWER- "Set your hot water heater temperature at or below 120
degrees Fahrenheit."

Rationale: The nurse should instruct the client to set the maximum hot
water temperature to no more than 49° C (120° F). The nurse should also
instruct the client to test the temperature of the bath water with her
elbow prior to bathing the newborn.

A nurse manager is assisting the orientation of a newly licensed nurse.

Which of the following actions by the nurse requires the nurse manager
to intervene? - ANSWER- Tells the hospital chaplain a client's diagnosis

Rationale: Discussing a client's diagnosis with the hospital chaplain is a

breach of client confidentiality and a violation of HIPAA.

A nurse is assessing a 2-month-old infant during a well-baby

examination. Which of the following actions should the nurse take to
assess the infant's rooting reflex? - ANSWER- Stroke the infant's cheek.
Rationale: The nurse should stroke the infant's cheek to assess the
rooting reflex, which should cause the infant to turn towards that side
and suck.

A nurse is providing client education to a postpartum client who has

decided to bottle feed the newborn. Which of the following instructions
should the nurse include in the teaching to help prevent the discomfort
of engorgement? - ANSWER- Place ice packs on the breasts for 15 min
several times per day.
The client should place ice packs on the breasts to reduce swelling and
relieve the pain caused by engorgement.

A nurse receives a request from a client to review the information in his

medical record. Which of the following responses should the nurse give?
- ANSWER- "There's a protocol for reviewing your medical record, and
I can initiate the process."

Rationale: The client's record is the legal property of the facility, but the
client has a right to access the record, obtain a copy of the record, and
request corrections to the document if there are discrepancies. According
to HIPAA, the nurse is responsible for following the facility's policy
when providing the client with access to the medical record.

A nurse is administering the cyclophosphamide orally to a school-age

child who has a neuroblastoma. Which of the following actions should
the nurse take when administering this medication? - ANSWER-
Maintain hydration with liberal fluid intake.
Rationale: The nurse should offer fluids frequently to maintain hydration
and prevent hemorrhagic cystitis, which is an adverse effect of this
medication.

A nurse in the delivery room is caring for a newborn immediately after

birth. Which of the following actions should the nurse take first? -
ANSWER- Dry the newborn.

Rationale: The greatest risk to the newborn is cold stress. Therefore, the
first action the nurse should take is to dry the newborn.

A nurse is reviewing the urinalysis report of a client who has acute

glomerulonephritis. Which of the following findings should the nurse
expect? - ANSWER- Protein

Rationale: A client who has glomerulonephritis has increased glomerular

permeability, which allows protein to filter into the urine. Therefore, the
nurse should expect proteinuria on the urinalysis report.

A nurse is initiating discharge planning for a client who had a stroke and
is experiencing right-sided weakness. Which of the following actions
should the nurse take first? - ANSWER- Request a referral for the client
to receive physical therapy.

Rationale: The greatest risk to this client is injury from falls. Therefore,
the first action the nurse should take is to request a referral for physical
therapy.
A nurse is teaching the parents of a preschooler about sleep promotion.
The parents report that their child is demonstrating reluctance in going to
bed at night and states, "I am not tired." Which of the following
statements by the parents indicate an understanding of the teaching? -
ANSWER- "We should read a story together every night before
bedtime."

Rationale: Preschoolers respond to rituals that prepare them for bed,

such as hearing a story or taking a bath.

A clinic nurse is caring for a client who is in the first trimester of

pregnancy. The client reports using acupressure bands on both wrists.
which of the followings statements by the client indicates that this
therapy is having the desired effect? - ANSWER- "I have not vomited as
much recently."

Rationale: Using an acupressure band on the wrists is a type of

complementary and alternative therapy that applies pressure to a specific
part of the body and can be used to alleviate nausea and vomiting.

A nurse is planning care for a client who has thrombocytopenia. Which

of the following instructions should the nurse include in the client's plan
of care? - ANSWER- Avoid venipunctures when possible.

Rationale: Clients who have thrombocytopenia have a decreased platelet

count and are at risk for bleeding. To reduce the risk for bleeding, the
nurse should avoid venipunctures when possible.
A nurse is preparing to administer 15 units of regular insulin along with
20 units of NPH insulin. Which of the following actions should the nurse
plan to take? - ANSWER- Inject 20 units of air into the NPH insulin
vial.

Rationale: The nurse should inject 20 units of air into the NPH insulin
vial and withdraw the needle without touching the insulin, then proceed
to inject 15 units of air into the regular insulin vial.

A nurse is caring for a client who is immediately postoperative following

a total vaginal hysterectomy. Which of the following actions should the
nurse take first? - ANSWER- Measure the client's vital signs.

Rationale: The first action the nurse should take when using the nursing
process is to assess the client. The nurse should monitor the client's vital
signs every 15 min until stable and then every 4 hr for the next 48 hr.

A nurse is providing discharge instructions to a client who has a new

prescription for amitriptyline to treat depression. The nurse should
identify that which of the following client statements indicates an
understanding of the teaching? - ANSWER- "I should watch for
common reactions like dry mouth and constipation."

Rationale: The nurse should reinforce that increasing dietary fiber, fluid
intake, and chewing sugar-free gum can alleviate the anticholinergic
effects of dry mouth and constipation.
A nurse is teaching a client who has a new prescription for estradiol. For
which of the following adverse effects of this medication should the
nurse instruct the client to monitor and report to the provider> -
ANSWER- Headaches

Rationale: The nurse should instruct the client to monitor for and report
headaches. Headaches can be an indication of a thromboembolic stroke
because estradiol increases the risk for adverse cardiovascular events.

A nurse is providing teaching to a parent of a child who has a permanent

tracheostomy tube. Identify the sequence of steps the parent should
follow to perform tracheostomy care. - ANSWER- When teaching the
parent to provide tracheostomy care, the nurse should instruct the parent
to first remove the inner cannula. Next, the nurse should instruct the
parent to remove the soiled dressing and then clean the stoma with 0.9%
sodium chloride irrigation. Finally, the nurse should instruct the parent
to change the tracheostomy collar.

A nurse is caring for a newborn who has herpes simplex virus (HSV).
Which of the following isolation precautions should the nurse initiate? -
ANSWER- Contact

Rationale: The nurse should initiate contact precautions because clients

transmit HSV by direct and indirect contact with others and the
environment. The nurse should wear gloves when in close contact with
the newborn.
A nurse is assessing a client who has antisocial personality disorder.
Which of the following manifestations should the nurse expect? -
ANSWER- Lack of remorse

Rationale: A client who has antisocial personality disorder is more likely

to show a lack of remorse.

A nurse is caring for a client who had a recent stroke. Prior to

transferring the client to the bedside commode, which of the following
actions should the nurse take first? - ANSWER- Assess the client for
functional limitations.

Rationale: When using the nursing process, the first action the nurse
should take is to assess the client's functional limitations to determine
how much the client can assist with the transfer.

A nurse is preparing to administer diazepam 0.3 mg/kg IV bolus to a

toddler who weighs 22 lb and is experiencing a grand mal seizure.
Available is diazepam solution for injection 5 mg/mL. How many mL
should the nurse administer? - ANSWER- 0.6 mL

A nurse is caring for a client who is in labor at 39 weeks of gestation.

During the second stage of labor, the nurse observes early decelerations
on the monitor tracing. Which of the following actions should the nurse
take? - ANSWER- Continue observing the fetal heart rate.
Rationale: Early decelerations indicate the progression of labor and are
an expected finding. The nurse should continue to monitor the fetus by
observing the fetal heart rate and tracing.

A nurse is interviewing a client who is now without a home due to a

natural disaster. After ensuring the client's safety, which of the following
actions should the nurse take first? - ANSWER- Determine the client's
perception of the personal impact of the crisis.

Rationale: The first action the nurse should take using the nursing
process is to assess the client. Therefore, the first action the nurse should
take is to determine the client's feelings and understanding of the natural
disaster and its personal impact.

A charge nurse is planning care for a client who has mechanical

restraints in place. Which of the following interventions should the nurse
include in the plan? - ANSWER- Provide a staff member to stay with the
client continuously.

Rationale: A staff member must remain continuously with a client who is

in restraints or view the client via audiovisual equipment, if necessary,
due to the risk of injury.

A nurse is performing tracheostomy care for a client who is

postoperative following a laryngectomy. Which of the following actions
should the nurse take when suctioning the client's airway? - ANSWER-
Apply suction for 10 seconds.
Rationale: The nurse should apply suction for only 5 to 15 seconds to
minimize oxygen loss.

A nurse is caring for a client who has a closed-head injury and is

receiving mechanical ventilation. The nurse should expect to administer
which of the following medications to reduce intracranial pressure? -
ANSWER- Mannitol

Rationale: The client should receive mannitol, an osmotic diuretic, to

reduce intracranial pressure caused by cerebral edema.

A charge nurse overhears two staff nurses in the hallway discussing the
nutritional status of a client who has anorexia nervosa. Which of the
following actions should the charge nurse take? - ANSWER- Tell the
nurses to stop the discussion.

Rationale: The nurses are violating client confidentiality by having the

discussion in a public hallway. The charge nurse should tell the nurses to
stop the discussion to prevent any further breach of confidentiality.

A community health nurse is performing triage tagging following a mass

casualty incident. On which of the following clients should the nurse
place a black tag? - ANSWER- A client who has significant head trauma
and agonal respirations
Rationale: The nurse should place a black tag on a client who has
significant head trauma and agonal respirations because this client is not
likely to recover or will require extensive resources for care.

A nurse is planning care for a client who has a deficit with cranial nerve
II. Which of the following actions should the nurse plan to take? -
ANSWER- Clear objects from the client's walking area.

Rationale: The nurse should plan to clear objects from the client's
walking area because CN II is the optic nerve and a deficit can result in
visual impairment which can lead to falls.

A nurse is teaching a client who is to start taking misoprostol and

currently is on long-term therapy with NSAIDs for arthritis. The nurse
should provide the client with which of the following information? -
ANSWER- Complete a serum pregnancy test before taking the
medication.

Rationale: Misoprostol can induce uterine contractions. Clients of

childbearing age must rule out pregnancy before taking misoprostol.

A nurse is creating a plan of care for a child who has acute lymphoid
leukemia and an absolute neutrophil count of 400/mm3. Which of the
following interventions should the nurse include in the plan? -
ANSWER- Withhold administering the varicella vaccine to the child.
Rationale: A child who has severe immunodeficiency should not receive
a live vaccine due to the risk of developing the disease. Inactivated
vaccines can be administered to children who are immunosuppressed.

A nurse is assessing a client who has a stage II pressure injury. Which of

the following wound characteristics should the nurse expect? -
ANSWER- Partial-thickness skin loss

Rationale: The nurse should expect to see partial-thickness skin loss or

blister formation in a client who has a stage II pressure injury.

A nurse in an emergency department is admitting a client who has

cardiac tamponade. Which of the following assessment findings should
the nurse expect? - ANSWER- Pulsus paradoxus

Rationale: The nurse should identify pulsus paradoxus, a finding in

which the systolic BP is 10 mm Hg or greater on expiration than
inspiration, as an expected finding of cardiac tamponade, along with
jugular vein distention, bradycardia, and hypotension.

A nurse is caring for a client who has had nausea and vomiting for the
past 2 days. The nurse should identify which of the following findings as
an indication the client is experiencing fluid volume deficit? -
ANSWER- Orthostatic hypotension
Rationale: Clients who have a fluid volume deficit can experience
orthostatic hypotension, which is a result of the body's inability to
maintain adequate blood pressure following position changes.

A nurse is assessing a client who has sickle cell anemia. The nurse
should identify which of the following findings as a manifestation of
vasoocclusive crisis? - ANSWER- Hematuria

Rationale: The nurse should identify hematuria as a manifestation of

vaso-occlusive sickle cell crisis resulting from ischemia of the kidneys

A nurse is caring for a client who has a potassium level of 3 mEq/L. For
which of the following manifestations should the nurse monitor? -
ANSWER- Decreased deep tendon reflexes

Rationale: A client who has hypokalemia can have muscle weakness and
decreased deep tendon reflexes.

A nurse is caring for four clients at the beginning of a shift. After

receiving change-of-shift report, which of the following clients should
the nurse attend to first? - ANSWER- A client who is confused and has
been attempting to get out of bed

Rationale: The nurse should recognize that a client who is confused and
has been attempting to get out of bed is at greatest risk for injury from a
fall. Therefore, the nurse should attend to this client first.
A client who is 24 hr postoperative following abdominal surgery refuses
to ambulate. Which of the following actions should the nurse take first? -
ANSWER- Ask the client to rate their pain level.

Rationale: Using the nursing process, the first action the nurse should
take is to assess the client's level of pain. If indicated, the nurse should
administer an analgesic, then wait 30 to 45 min to allow the analgesic to
take effect before encouraging the client to ambulate. Management of
the client's pain is a priority for encouraging postoperative activity.

A nurse is teaching a client about foods high in vitamin A. Which of the

following foods should the nurse recommend as having the highest
amount of vitamin A? - ANSWER- 1 medium raw carrot

Rationale: The nurse should identify that 1 medium raw carrot contains
2,025 mcg/dL of vitamin A and is therefore the best food to recommend
to the client.

A nurse working in a long-term care facility is assessing an adult client.

Which of the following findings places the client at risk for development
of a pressure injurty? - ANSWER- Recent weight loss

Rationale: Weight loss can increase the risk for pressure injury.
Inadequate nutrition will cause decreased nutrients for the skin and
tissues and increases the chance for shearing against the bony
prominences.
A nurse is teaching a client who has a new prescription for digoxin about
manifestations of toxicity. Which of the following findings should the
nurse include in the teaching? - ANSWER- Nausea

Rationale: The nurse should instruct the client to monitor for and report
manifestations of digoxin toxicity, such as nausea, anorexia, abdominal
pain, bradycardia, and visual changes.

A home health nurse is assessing a 2-week-old newborn who had a birth

weight of 3.64 kg (8 lb) and is being breastfed. Which of the following
findings indicates effective breastfeeding? - ANSWER- The newborn
has six to eight wet diapers per day.

Rationale: Measuring the number of wet diapers per day is an effective

measurement of adequate intake. Six to eight wet diapers each day after
the fourth day of life indicates effective breastfeeding.

A nurse is reviewing the laboratory findings of a client who is

experiencing chest pain. The nurse should identify that an elevation in
which of the following laboratory values indicates cellular injury of
myocardial tissue? - ANSWER- Troponin T

Rationale: Troponin T is a myocardial muscle protein that is released

into circulation after cardiac injury. The nurse should expect increases in
the client's troponin level within 2 to 3 hr following a myocardial injury.
A nurse is teaching a newly admitted client who has heart failure about
advance directives. Which of the following statements should the nurse
make? - ANSWER- "You should complete advance directives in the
event you cannot express your own wishes."

Rationale: The client should prepare advance directives to make their

wishes known should they be unable to communicate them in the future.

A nurse on a mental health unit is caring for a client who tells the nurse
that she does not want to receive a scheduled dose of lorazepam IM.
Which of the following actions should the nurse take? - ANSWER-
Document the client's refusal of the medication.

Rationale: The client has the right to refuse medication. The nurse
should document the refusal in the client's medical record.

A nurse is preparing to administer 2 units of fresh frozen plasma to a

client. Which of the following actions should the nurse plan to take ? -
ANSWER- Enter the plasma product number into the client's medical
record.

Rationale: The nurse should complete documentation following blood

product therapy, which includes recording the type of product, amount
administered, product number, infusion time, and client response.

A nurse is providing discharge instructions to a client who has a new

prescription of warfarin. Which of the following client statements should
the nurse identify as an indication that the client understands the
teaching? - ANSWER- "I should report a change in the color of my
stools."

Rationale: The nurse should inform the client that red, black, or tarry
stools can indicate bleeding, an adverse effect of warfarin, and the client
should report these findings to the provider.

A charge nurse is preparing to administer 0900 medications and is told

by the pharmacy staff that the medications are not available.
Medications availability has been ongoing problem, and the charge
nurse has previously discussed this issue with the pharmacy staff. Which
of the following actions should the charge nurse take first? - ANSWER-
Inform the nurse manager of the issue.

Rationale: The greatest risk to clients is injury from not receiving

medications on time and developing a medical complication. Therefore,
the priority intervention the charge nurse should take is to follow the
chain of command and contact the nurse manager.

A nurse is teaching about total parenteral nutrition (TPN) and IV lipid

emulsions with a client who has an extensive burn injury. Which of the
following information should the nurse include? - ANSWER- "You will
receive fingersticks for blood glucose testing."

Rationale: A client who is receiving TPN is at risk for hyperglycemia

due to the dextrose in the TPN solution. Therefore, the client will require
blood glucose monitoring
A nurse is caring for a client who has a fractured femur and has had a
fiberglass leg cylinder cast for 24 hr. Which of the following assessment
findings should the nurse identify as the priority? - ANSWER- The
client's heel is reddened and tender.

Rationale: The greatest risk to this client is injury from a pressure injury.
Therefore, the priority assessment finding the nurse should identify is a
reddened and tender heel.

A mental health nurse is conducting the first of several meetings with a

client whose partner recently died. The nurse should perform which of
the following actions to establish trust during the orientation phase of the
nurse-client relationship? - ANSWER- Establish the termination date of
therapy.

Rationale: This task occurs in the orientation phase of a therapeutic

relationship.

A nurse is performing gastric lavage for a client who has gastrointestinal

bleeding an an NG tube in place. Which of the following actions should
the nurse take? - ANSWER- Use 0.9% sodium chloride for irrigation of
the NG tube.

Rationale: The nurse should use 0.9% sodium chloride, sterile water, or
tap water for irrigation of the client's NG tube.
A nurse is assessing a client who has been taking lithium carbonate for
the past month to treat bipolar disorder. Which of the following
assessment findings should the nurse identify as the priority? -
ANSWER- Confusion

Rationale: When using the urgent vs. nonurgent approach to client care,
the nurse should determine that the priority finding is confusion because
it is an early manifestation of lithium toxicity. The nurse should monitor
the client for additional indications of lithium toxicity, including coarse
hand tremors, incoordination, ECG changes, and sedation.

A nurse is preparing to perform an intermittent urinary catheterization

for a client who has urinary retention. Which of the following images
indicates the catheter the nurse should use? - ANSWER- A straight
urinary catheter, which should be used to perform an intermittent
catheterization for a client who has urinary retention.

A nurse is reviewing the ABG results of a client who has COPD. The
results include a pH of 7.3, PaO2 56 mm Hg, PaCO2 54 mm Hg, HCO
26 mEq/L, SaO2 87%. Which of the following is the correct
interpretation of these values? - ANSWER- Uncompensated respiratory
acidosis

Rationale: A pH of 7.3 is below the expected reference range and

indicates the client has acidosis. The PaCO2 of 54 mm Hg is above the
expected reference range, which, when combined with the low pH,
indicates that the acidosis has a respiratory origin. The HCO3- of 26
mEq/L is within the expected reference range, indicating that the
acidosis is not metabolic in origin and the body has not yet corrected the
imbalance through compensation.

A nurse is assessing a client who has skeletal traction for a femur

fracture. Which of the following findings should the nurse identify as the
priority? - ANSWER- Upper chest petechiae

Rationale: The greatest risk to this client is organ damage from fat
embolism syndrome, a life-threatening complication of fractures. In fat
embolism syndrome, a fat embolus enters the blood stream and can
obstruct blood vessels of a major organ, such as the lung, kidney, or
brain. Manifestations include petechiae on the upper torso, dyspnea,
hypoxia, headache, lethargy, and confusion. Therefore, the nurse should
identify this as the priority finding.

A nurse in an acute mental health facility is planning care for a client

who has anorexia nervosa. Which of the following interventions should
the nurse include in the client's plan of care? - ANSWER- Supervise the
client during and after eating.

Rationale: The nurse should monitor the client during and for 1 hr after
meals to prevent the client from hiding food or purging.

A nurse is preparing a sterile field in order to insert an indwelling

urinary catheter for a male client. Which of the following techniques
should the nurse use to maintain surgical aseptic technique? -
ANSWER- Set the catheter tray on the overbed table at waist height.
Rationale: To maintain sterility, the nurse should place the catheter tray
on a work surface at or above waist level.

A nurse is caring for a child who is experiencing a tonic clonic seizure.

Which of the following actions should the nurse take? - ANSWER-
Place the child in a side-lying position.

Rationale: The nurse should place the child in a side-lying position

during a seizure to maintain a patent airway, decrease the risk of
aspiration, and facilitate drainage of oral secretions.

A nurse manager is preparing a newly licensed nurse's performance

appraisal. Which of the following methods should the nurse manager use
to evaluate the nurse's time management skills? - ANSWER- Maintain
regular notes about the nurse's time management skills.

Rationale: Maintaining notes over a period of time provides a

comprehensive view of the nurse's abilities so the manager can identify
trends in the nurse's overall performance.