ATI Questions for Review
A nurse is providing preoperative teaching for a client who will undergo laser-assisted in situ keratomileusis (LASIK) surgery. Which of the following pieces of information should the nurse include? A. "You might need glasses after the surgery." B. "You may drive home after the procedure." C. "Continue to wear your contact lenses until the day of the surgery." D. "Expect complete healing and clear vision in about a week."
A. "You might need glasses after the surgery."
A nurse is caring for a client who has diabetes insipidus. For which of the following findings should the nurse monitor? A. Proteinuria B. Oliguria C. Polyuria D. Glycosuria
C. Polyuria
A nurse is providing teaching for a client about hormonal changes during pregnancy. The nurse identifies that which of the following hormones plays a key role in preventing miscarriage? A. Oxytocin B. Prolactin C. Progesterone D. Estrogen
C. Progesterone
A nurse is caring for a client who has xerostomia with a lack of saliva. Which of the following nutrients will be affected by the lack of salivary amylase? A. Fat B. Protein C. Starch D. Fiber
C. Starch
A nurse is assessing a client who is taking buspirone to treat generalized anxiety disorder. Which of the following findings should the nurse identify as an adverse effect of this medication? A. Arthralgia B. Photophobia C. Xerostomia D. Bradycardia
C. Xerostomia
A nurse manager is orientating newly licensed nurses to a facility and is emphasizing the importance of practicing within standards of care. To which of the following legal concepts is the nurse manager referring? A. Punitive damages B. Intentional torts C. Good Samaritan laws D. Professional negligence
D. Professional negligence
A home-health nurse is caring for a client who has cancer and is using a fentanyl transdermal patch for pain control. Which of the following actions should the nurse take when caring for this client? A. Avoid using a heating pad on the area with the patch B. To decrease the dose, cut the patch in half C. Dispose of the used patch in the trash can D. Assess the client for urinary retention every 8 hr
A. Avoid using a heating pad on the area with the patch
A nurse is providing teaching about baclofen to the guardian of a toddler who has cerebral palsy. Which of the following adverse effects should the nurse include? A. Bradycardia B. Muscle weakness C. Diarrhea D. Dry skin
B. Muscle weakness
A nurse is teaching a client about a new prescription for extended-release oxycodone for pain management. Which of the following statements should the nurse include in the teaching? A. "Swallow this medication whole." B. "Take this medication before meals and at bedtime." C. "Constipation decreases with continued use." D. "Avoid taking other supplemental analgesics with this medication."
A. "Swallow this medication whole."
A nurse is preparing to administer a client's anticoagulant medication. The client states, "I don't like to take this medication. I always have to get my blood checked." Which of the following responses should the nurse make? A. "You can refuse the medication. I will notify your provider." B. "This medication is given all the time to clients, and they don't have a problem." C. "I will come back later to give you the medication." D. "You need to take this medication in order to feel better."
A. "You can refuse the medication. I will notify your provider."
An 18-month-old infant has Pneumocystis carinii pneumonia. Results of enzyme-linked immunosorbent assay (ELISA) testing indicate that she is HIV positive. When planning care, the nurse should consider which of the following factors? A. The infant's mother is likely HIV positive. B. The infant's ELISA test result is probably a false positive for HIV. C. Antiretroviral medications are inappropriate for infants and children who have HIV. D. HIV-positive status is a contraindication for measles, mumps, and rubella immunizations
A. The infant's mother is likely HIV positive.
A nurse is assessing the pH of a client's gastric fluid to confirm the placement of an NG tube in the stomach. Which of the following pH values should the nurse expect? A. 6 B. 2 C. 10 D. 8
B. 2
A nurse is planning care for an older adult client following abdominal surgery for a bowel obstruction. Which of the following pieces of information about pain management should the nurse consider when planning care? A. Older adult clients have a diminished ability to perceive pain. B. Older adult clients should not take narcotics for pain control. C. Older adult clients have increased pain as a normal part of aging. D. Older adult clients are sensitive to the analgesic effect of opiates.
D. Older adult clients are sensitive to the analgesic effect of opiates.
A nurse is receiving report on a client who has Clostridium difficile and is being transferred from another unit. Which of the following precautions should the nurse take? A. Place the client in a negative air flow room. B. Clean the client's room with antibacterial disinfectant. C. Wear a mask when entering the client's room. D. Perform hand hygiene with nonantimicrobial soap and water after client care
D. Perform hand hygiene with nonantimicrobial soap and water after client care
A nurse on an eating disorders acute care unit is assessing a client and observes the presence of lanugo on her skin. The nurse should identify that this finding is consistent with which of the following eating disorders? A. Anorexia nervosa B. Bulimia nervosa C. Binge eating disorder D. Pica
A. Anorexia nervosa
A nurse is caring for a client who has a history of severe multiple sclerosis and asks the nurse about completing a living will. Which of the following statements should the nurse make? A. "I will provide you with the information you need to complete advance directives." B. "I will contact your provider to inform him of your desire to complete a living will." C. "Your attorney will need to review the document before it can be enacted." D. "Once your living will is complete and on le, the choices you make are final."
A. "I will provide you with the information you need to complete advance directives."
A nurse is caring for a client who is undergoing treatment for hypertension. Which of the following statements indicates that the client is adhering to the treatment plan? A. "I would never have believed I could get used to enjoying my food without salt." B. "My blood pressure device at home usually shows about 156 over 98 or so." C. "I make sure I take my blood pressure medicine when I have headaches." D. "My blood pressure pills are very expensive. Could I take a cheaper medication?"
A. "I would never have believed I could get used to enjoying my food without salt."
A nurse is teaching a client who has a prescription for chenodiol for the treatment of gallstones. Which of the following client statements indicates an understanding of the teaching? A. "Treatment should last for a couple of months." B. "Liver function tests are required while taking this medication." C. "I should contact my provider if I experience diarrhea." D. "I can continue to take this medication if I become pregnant."
B. "Liver function tests are required while taking this medication."
A nurse is caring for a client who is at 26 weeks gestation and reports constipation. Which of the following responses by the nurse is appropriate? A. "You should drink 1 oz of mineral oil every morning." B. "You should walk for at least 30 min every day." C. "You should eat at least 3 oz of red meat per day." D. "You should stop taking your prenatal vitamin."
B. "You should walk for at least 30 min every day."
A nurse at a long-term care facility notes that a client with dementia is having problems with orientation. Which of the following actions should the nurse take to improve the client's level of orientation? A. Encourage the client to make choices about meals and activities B. Use written signs to label specific rooms C. Post a large calendar on the bulletin board D. Place an electronic wander alert bracelet on the client's wrist
C. Post a large calendar on the bulletin board
A nurse manager notes several recent conflicts among nurses on different shifts. Which of the following strategies should the nurse manager use to resolve these conflicts? A. Have the charge nurses for each shift get together and discuss the issues between shifts. B. Direct the nurses from each shift to discuss their issues and present solutions to the nurse manager. C. Set up a series of meetings for all staff members to attend to discuss issues. D. Remain uninvolved and allow the nurses from each shift to resolve the issues among themselves.
C. Set up a series of meetings for all staff members to attend to discuss issues.
A nurse is caring for a client who is attempting a trial of labor (TOL) after several cesarean births. The client reports a sudden onset of constant abdominal pain, and the nurse observes a prolonged deceleration on the fetal heart rate tracing. Which of the following actions should the nurse take? A. Assist the client to the bathroom to empty her bladder B. Place the client in a knee-chest position C. Plan to administer calcium gluconate D. Prepare the client for an emergency cesarean delivery
D. Prepare the client for an emergency cesarean delivery
A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following statements should the nurse include? A. "Notify your provider if you notice cracking on your nipples." B. "Notify your provider if you have not had a bowel movement within 5 days." C. "Notify your provider if your breasts leak when you shower." D. "Notify your provider if your vaginal discharge is a brownish-red color."
A. "Notify your provider if you notice cracking on your nipples."
A nurse is teaching a client who is beginning a vegan diet and is concerned about maintaining an adequate protein intake. Which of the following food servings should the nurse recommend due to the high amount of protein? A. 1/2 cup tomato soup B. 1/2 cup of hummus C. 2 tablespoons of peanut butter D. 1 cup penne pasta
B. 1/2 cup of hummus
A nurse is conducting an admission assessment for an older adult client. Which of the following actions should the nurse take to collect subjective data? A. Leave the client a written questionnaire to fill out in private B. Allow sufficient time for the client to respond to the questions C. Talk to family members to obtain the client's health history D. Obtain the client's health history from the medical record
B. Allow sufficient time for the client to respond to the questions
A nurse is caring for a client who has a platelet count of 50,000/mm^3. After discontinuing the client's peripheral IV site, which of the following actions should the nurse take? A. Apply warm compresses B. Apply pressure to the catheter removal site for 5 min C. Place the affected arm in a dependent position D. Clean the insertion site with alcohol
B. Apply pressure to the catheter removal site for 5 min
A nurse is planning care for a client who is postoperative following a gastrectomy. Which of the following strategies should the nurse include to help prevent dumping syndrome? A. Have the client drink plenty of water with meals B. Eliminate simple sugars and sugar alcohols from the client's diet C. Limit the client's intake to 2 meals per day D. Offer the client meals that are low in protein or protein-free
B. Eliminate simple sugars and sugar alcohols from the client's diet
A nurse is initiating seizure precautions for a client who has a seizure disorder. Which of the following pieces of equipment should the nurse have readily available at the client's bedside? A. Vest restraint B. Tongue blade C. Oxygen equipment D. Neck brace
C. Oxygen equipment
A nurse is planning care for a client following a total hip arthroplasty. Which of the following interventions should the nurse include in the plan? A. Position the client with her legs adducted B. Internally rotate the client's affected hip C. Place a pillow between the client's legs D. Instruct the client to avoid flexing her hip more than 95º
C. Place a pillow between the client's legs
A nurse is caring for a 1-year-old infant who has chronic otitis media. The nurse should identify that which of the following areas is at risk of a delay in development? A. Fine motor skills B. Visual acuity C. Speech patterns D. Hand-to-eye coordination
C. Speech patterns
A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2°C (102.6°F), a heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority? A. Heart rate of 105/min B. Soft nontender abdomen C. Temperature D. Overdue menses
C. Temperature
A nurse is providing teaching to a client who has a history of tonic-clonic seizures and is scheduled for a standard electroencephalogram (EEG). Which of the following instructions should the nurse include in the teaching? A. Remain NPO 6 to 8 hr prior to the EEG B. Take a sedative the night prior to the EEG C. Thoroughly shampoo her hair prior to the EEG D. Sleep for at least 8 hr during the night prior to the test
C. Thoroughly shampoo her hair prior to the EEG
A nurse is preparing to transfuse a unit of packed red blood cells (RBCs) for a client who has anemia. Which of the following actions should the nurse take first? A. Hang an IV infusion of 0.9% sodium chloride with the blood B. Compare the client's identification number with the number on the blood C. Witness the informed consent document D. Obtain pretransfusion vital signs
C. Witness the informed consent document
A nurse is caring for a client who has dementia and is experiencing anxiety. Which of the following actions should the nurse take? A. Place a vest restraint on the client to protect others in the environment B. Provide a variety of routines to keep the client from getting bored C. Explain to the client that episodes of anxiety will decrease over time D. Redirect the client to a different activity with a small group of people
D. Redirect the client to a different activity with a small group of people
A nurse is performing a brief mental status examination for a client. To assess a client's ability to concentrate, the nurse should do which of the following? A. Point to 2 objects and ask the client to name them B. Ask the client to name the months of the year in reverse C. Say 3 words and ask the client to repeat them D. Ask the client to write a sentence
B. Ask the client to name the months of the year in reverse
A nurse is caring for an older adult client who has a new onset of type 2 diabetes mellitus. Which of the following physiological changes can contribute to the development of type 2 diabetes? A. Increased production of insulin by the pancreas B. Decreased sensitivity to the circulating insulin C. Increased rate of glucose metabolism D. Decreased release of glycogen by the liver
B. Decreased sensitivity to the circulating insulin
A nurse is teaching the guardian of an infant about the diphtheria, tetanus, and pertussis (DTaP) vaccine. Which of the following pieces of information should the nurse include in the teaching? A. "Routine immunization for DTaP consists of 3 injections." B. "The first immunization for DTaP in the series is given at 2 months." C. "DTaP immunization has been replaced with DTP." D. "This immunization is administered subcutaneously."
B. "The first immunization for DTaP in the series is given at 2 months."
A nurse is caring for an older adult client who is expressing feelings of grief and longing for his earlier life. Which of the following actions should the nurse take? A. Listen attentively and allow the client to talk about the past B. Change the topic of conversation C. Let the client know that this issue is common for older adult clients D. Tell the client about younger clients who are facing worse situations
A. Listen attentively and allow the client to talk about the past
A nurse is preparing a client for discharge who is postoperative following a conventional lumbar disk excision. Which of the following statements indicates that the client understands the nurse's instructions? A. "I should have no problem climbing stairs when I get home." B. "I'll wait about 3 weeks before I return to my usual activities." C. "I'll use my heating pad if I feel any muscle spasms in my back." D. "I can go back to driving in about 2 weeks or so."
C. "I'll use my heating pad if I feel any muscle spasms in my back."
A nurse is calculating the protein needs of a young adult client who weighs 132 lb. The RDA for protein for an adult who has no medical conditions is 0.8 g/kg. How many grams of protein per day should the nurse recommend for this client?(Fill in the blank with the numeric value only.)
48
A nurse is providing teaching for a client who has a prescription for a low-sodium diet to manage hypertension. Which of the following statements by the client indicates an understanding of the teaching? A. "I can snack on fresh fruit." B. "I can continue to eat lunchmeat sandwiches." C. "I can have cottage cheese with my meals." D. "Canned soup is a good lunch option."
A. "I can snack on fresh fruit."
A nurse is teaching a client with heart disease about a low cholesterol diet. Which of the following client statements indicates the teaching was effective? A. "I should remove the skin from poultry before eating it." B. "I will eat seafood once per week." C. "I should use margarine when preparing meals." D. "I can use whole milk in my oatmeal."
A. "I should remove the skin from poultry before eating it."
A nurse at a family-planning clinic is preparing to teach a class about how to use a diaphragm. Which of the following pieces of information should the nurse plan to include in the teaching? A. "Use spermicidal jelly whenever you use your diaphragm." B. "Insert the diaphragm about 8 hr before sexual activity." C. "You should remove the diaphragm 30 min after intercourse." D. "A diaphragm comes in a single size and does not require fitting."
A. "Use spermicidal jelly whenever you use your diaphragm."
A nurse is rewarming a client following coronary artery bypass graft (CABG) surgery. For which of the following complications of the rewarming process should the nurse monitor the client? A. Acidosis B. Infection C. Hypertension D. Cardiac tamponade
A. Acidosis
A nurse manager is planning staff development activities for the unit's new unlicensed assistive personnel (UAP). Which of the following activities should the nurse manager perform first? A. Determine the learning needs of the UAPs B. Administer a skills pretest to the new UAPs C. Provide the new UAPs with a performance checklist D. Ask the UAPs about any weaknesses they may have
A. Determine the learning needs of the UAPs
A nurse is planning care for a client who has dissociative disorder and is experiencing flashbacks while in public. Which of the following interventions should the nurse include in the plan to help the client recognize and counter the flashbacks? A. Encourage reality testing B. Provide opportunities for socialization C. Consistently remind the client of past traumatic events D. Discourage client expressions of negative feelings
A. Encourage reality testing
A nurse is preparing to administer the varicella vaccine to a 12-month-old infant. The nurse asks the infant's guardian if the infant has any allergies. Which of the following allergies is a contraindication to the infant receiving the vaccine? A. Gelatin B. Milk C. Eggs D. Peanuts
A. Gelatin
A nurse is removing personal protective equipment (PPE) after performing a procedure for a client who requires isolation precautions. Which of the following items of PPE should the nurse remove first? A. Gloves B. Gown C. Eyewear D. Mask
A. Gloves
A nurse is completing a medication history for a client who reports using fish oil as a dietary supplement. Which of the following substances in fish oil should the nurse recognize as a health benefit to the client? A. Omega-3 fatty acids B. Antioxidants C. Vitamins A, D, and C D. Beta-carotene
A. Omega-3 fatty acids
A nurse is caring for a newly admitted newborn who is large for gestational age. After 30 min, the newborn becomes jittery and lethargic with hypotonic muscles and a cry that is different from the time of admission. Which of the following actions should the nurse take? A. Perform a heel stick to check the newborn's glucose level B. Obtain a prescription for serum substance screening C. Provide a feeding of sterile water D. Screen the newborn for phenylketonuria (PKU)
A. Perform a heel stick to check the newborn's glucose level
During a neurological assessment, a nurse asks the client to name all of his children, their ages, and their birth dates. Which of the following types of memory is the nurse testing? A. Remote B. Sensory C. Immediate D. Recall
A. Remote
A nurse is providing teaching about home safety to the parent of a 2-month-old infant. Which of the following information should the nurse include? A. Remove bibs before the infant goes to sleep B. Cover the infant with a lightweight blanket at bedtime C. Place the infant in direct sunlight for at least 10 minutes each day D. Set the hot water heater to 60°C (140°F)
A. Remove bibs before the infant goes to sleep
A nurse is teaching a client who has a new prescription for phenytoin. The nurse should inform the client that which of the following adverse effects can occur with the abrupt withdrawal of phenytoin? A. Status epilepticus B. Bleeding gums C. Disorientation D. Severe nausea
A. Status epilepticus
A nurse is preparing to assess a 2-year-old toddler. Which of the following behaviors should the nurse expect during the examination? A. The child prefers to sit on the parent's lap during the examination B. The child is interested in how the examination equipment works C. The child asks specific questions about body functions D. The child questions how her development compares to other children at the same age
A. The child prefers to sit on the parent's lap during the examination
A nurse is assessing a client who sustained a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure? A. Widened pulse pressure B. Tachycardia C. Periorbital edema D. Decrease in urine output
A. Widened pulse pressure
A nurse is checking paradoxical blood pressure of a client who has a possible cardiac tamponade. In what order should the nurse complete the following steps?(Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) A. Identify the first BP sounds audible on expiration and then on inspiration. B. Palpate the blood pressure and inflate the cuff above the systolic pressure. C. Deflate the cuff slowly and listen for the first audible sounds. D. Subtract the inspiratory pressure from the expiratory pressure. E. Inspect for jugular venous distention and notify the provider.
B - C - A - D - E
A nurse is teaching an adolescent about managing asthma and using a peak expiratory flow meter. Which of the following statements by the client demonstrates an understanding of the teaching? A. "I will use my peak flow meter whenever I feel short of breath." B. "I will continue to take my medication when my peak flow rate is in the green zone." C. "I need to use the average of 3 readings when I measure my flow rate." D. "My asthma is being controlled if my flow rate is in the yellow zone."
B. "I will continue to take my medication when my peak flow rate is in the green zone."
A nurse is caring for a group of clients who have mobility issues. Which of the following clients is at the greatest risk for a complication? A. A 3-year-old client who has a burned foot B. An 80-year-old client who has a fractured hip C. A 30-year-old client who has a cast applied for a fractured ankle D. A 42-year-old client who has an indwelling urinary catheter
B. An 80-year-old client who has a fractured hip
A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include? A. Blow into the spirometer to elevate the balls in the device B. Cough deeply after each use C. Clean the mouthpiece with an alcohol swab after each use D. Use the spirometer every 8 hr
B. Cough deeply after each use
A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? A. Pitting peripheral edema B. Crackles in the lung bases C. Jugular vein distention D. Hepatomegaly
B. Crackles in the lung bases
A nurse is teaching a client who has diabetes mellitus about hypoglycemia. Which of the following manifestations should the nurse include? (Select all that apply.) A. Bradycardia B. Diaphoresis C. Deep, rapid respirations D. Palpitations E. Shakiness
B. Diaphoresis D. Palpitations E. Shakiness
A nurse is preparing an in-service presentation about the management of myocardial infarction (MI). Death following MI is often a result of which of the following complications? A. Cardiogenic shock B. Dysrhythmias C. Heart failure D. Pulmonary edema
B. Dysrhythmias
A nurse is caring for a child who has a diagnosis of terminal brain cancer. The mother states, "I feel numb and can't believe this is happening to us." Which of the following interventions by the nurse is the first priority? A. Explore effective ways of family coping B. Encourage the family's expression of their feelings C. Discuss the disease and its manifestations with family members D. Instruct the family about anticipatory grieving
B. Encourage the family's expression of their feelings
A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect? A. Altered level of consciousness B. Impaired judgment C. Rapid change in personality D. Disturbances in perception
B. Impaired judgment
A nurse is reviewing the medical record for a client who has a migraine and a prescription for sumatriptan. Which of the following factors in the client's medical history should the nurse identify as a contraindication to receiving sumatriptan? A. Renal impairment B. Ischemic heart disease C. Severe osteoporosis D. Cirrhosis
B. Ischemic heart disease
A nurse is reviewing the medication administration record of a client who has impaired swallowing. The nurse should crush the medication when administering which of the following prescriptions? A. Aspirin EC 80 mg PO daily B. Levothyroxine 75 mcg PO q AM before breakfast C. Metformin XR 500 mg PO daily D. Nitroglycerin 0.3 mg SL PRN chest pain, may repeat q 5 min for 2 additional doses
B. Levothyroxine 75 mcg PO q AM before breakfast
A nurse is assessing a child who has a ventricular septal defect. Which of the following findings should the nurse expect? A. Diastolic murmur B. Murmur at the left sternal border C. Cyanosis that increases with crying D. Widened pulse pressure
B. Murmur at the left sternal border
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention? A. Obtaining hydrogen peroxide for tracheostomy care B. Obtaining cotton balls for tracheostomy care C. Obtaining sterile gloves for tracheostomy care D. Obtaining a sterile brush for tracheostomy care
B. Obtaining cotton balls for tracheostomy care
A nurse is providing discharge teaching to the family of a client who has a new diagnosis of a seizure disorder. The nurse should instruct the client's family to take which of the following actions first in the event of a seizure? A. Reorient the client B. Protect the client's head C. Loosen constrictive clothing D. Turn the client onto his side
B. Protect the client's head
A charge nurse is discussing ethics with a newly licensed nurse. Which of the following actions should the charge nurse include as an example of beneficence? A. Taking a continuing education course about recognizing risk factors of suicide B. Spending extra time reorienting a client who is experiencing command hallucinations C. Acknowledging and accepting a client's refusal of a psychotropic medication D. Describing the purpose, action, and side effects of a psychotropic medication
B. Spending extra time reorienting a client who is experiencing command hallucinations
A nurse is teaching a client who has polycythemia vera about self-care measures. Which of the following interventions should the nurse include? A. "Drink at least 1 liter of fluid each day." B. "Continuously wear support hose." C. "Elevate your legs when sitting." D. "Use dental floss daily."
C. "Elevate your legs when sitting."
A nurse is providing teaching to a client with a new diagnosis of heart failure who has a prescription for furosemide. Which of the following statements should the nurse include in the teaching? A. "You can take ibuprofen for headaches while taking this medication." B. "You may experience increased swelling in your lower extremities while taking this medication." C. "You should eat foods that are high in potassium while taking this medication." D. "You should take this medication at bedtime."
C. "You should eat foods that are high in potassium while taking this medication."
A nurse is caring for a client who has tardive dyskinesia. Which of the following tools should the nurse use in performing an assessment on the client? A. CAGE Assessment B. Hamilton Anxiety Rating Scale C. Abnormal Involuntary Movement Scale (AIMS) D. SAFE-T Too
C. Abnormal Involuntary Movement Scale (AIMS)
A nurse is assessing a 12-hour-old newborn and notes a respiratory rate of 44/min with shallow respirations and periods of apnea lasting up to 10 sec. Which of the following actions should the nurse take? A. Perform chest percussion B. Place the newborn in a prone position C. Continue routine monitoring D. Request a prescription for supplemental oxygen
C. Continue routine monitoring
A nurse is assessing an older adult client who states he is homeless. Which of the following findings should the nurse document as comorbidities for this client? A. Inadequate shelter and clothing for the weather B. Malnutrition and poverty C. Dementia and tuberculosis D. Lack of preventive health care and immunizations
C. Dementia and tuberculosis
A nurse is preparing a client who has a brain tumor for computed tomography (CT). Which of the following factors affects the manner in which the nurse will prepare the client for the scan? A. No food or fluids consumed for 4 hr B. Difficulty recalling recent events C. Development of hives when eating shrimp D. Paresthesias in both hands
C. Development of hives when eating shrimp
A nurse is assessing a 24-month-old toddler who has a new diagnosis of autism spectrum disorder (ASD). Which of the following findings should the nurse expect? A. Wanting to be held frequently B. Ability to build a tower of 10 cubes C. Impaired language skills D. Ability to stand on 1 foot
C. Impaired language skills
A nurse is assisting with the informed consent process for a client who is scheduled for a below the-knee amputation. The client asks the nurse, "Why are they making me have this surgery today? I don't understand why they are doing this." Which of the following actions should the nurse take? A. Complete an incident report. B. Administer an antianxiety medication. C. Notify the provider of the client's comments. D. Answer the client's questions and verify understanding
C. Notify the provider of the client's comments.
A nurse is preparing a client for an electroencephalogram (EEG). When the client asks the nurse what this test does, which of the following responses should the nurse provide? A. "An EEG measures the electric signals to your brain from hearing, sight, and touch." B. "An EEG measures the electrical activity in your muscles." C. "An EEG identifies the magnetic fields produced by electrical activity in your brain." D. "An EEG records the electrical activity of your brain cells."
D. "An EEG records the electrical activity of your brain cells."
A nurse is providing teaching to a client who is scheduled to start taking alendronate sodium. Which of the following recommendations should the nurse include in the teaching? A. "The medication may be crushed if you have difficulty swallowing it." B. "Drink a full glass of milk when you take the medication." C. "Take the medication at bedtime." D. "Discontinue the medication if you develop heartburn."
D. "Discontinue the medication if you develop heartburn."
A nurse is teaching a client who has an anxiety disorder about nonpharmacological ways to promote good sleep habits. Which of the following recommendations should the nurse make? A. "Schedule 20 minutes of aerobic exercise during the hour before bedtime." B. "Eliminate all caffeinated beverages from your diet." C. "Sleep for extra time when you can." D. "Eat a light snack containing carbohydrates before bedtime."
D. "Eat a light snack containing carbohydrates before bedtime."
A postpartum nurse is caring for a client who reports excessive sweating during the first night after delivery. Which of the following statements should the nurse make? A. "This is an attempt by your body to retain the fluid gained during pregnancy." B. "This is caused by an increase in your estrogen hormonal levels." C. "This is caused by the increased pressure on your veins in your lower legs." D. "This is a source of your fluid loss after delivery."
D. "This is a source of your fluid loss after delivery."
A nurse is assessing a client who has a high-thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia? A. Flushing of the lower extremities B. Hypotension C. Tachycardia D. Report of a headache
D. Report of a headache
A nurse is caring for a client who has a left intracranial hemorrhage from a stroke. Which of the following findings should the nurse expect? A. Spasticity of the left foot B. Negative Babinski reflex C. Ocular hypertension D. Right-sided hemiplegia
D. Right-sided hemiplegia
A nurse is caring for a client who is in labor and is reporting intense pain during contractions. The client has no previous knowledge of nonpharmacological comfort measures. Which of the following nursing interventions should the nurse implement? A. Self-hypnosis B. Biofeedback C. Acupuncture D. Slow-paced breathing
D. Slow-paced breathing
A nurse is providing discharge teaching to a client who has heart failure and a prescription for digoxin 0.125 mg PO daily and furosemide 20 mg PO daily. Which of the following statements by the client indicates an understanding of the teaching? A. "I know that blurred vision is expected to happen while I'm taking digoxin." B. "I will measure my urine output each day and document it in my diary." C. "I will skip a dose of my digoxin if my resting heart rate is below 72 beats per minute." D. "I will eat fruits and vegetables that have a high potassium content every day."
D. "I will eat fruits and vegetables that have a high potassium content every day."
A nurse is teaching the parent of a 12-month-old infant about nutrition. Which of the following statements by the parent indicates a need for further teaching? A. "I can give my baby 4 oz of juice to drink each day." B. "I will offer my baby dry cereal and chilled banana slices as snacks." C. "I am introducing my baby to the same foods the family eats." D. "My infant drinks at least 2 qt of skim milk each day."
D. "My infant drinks at least 2 qt of skim milk each day."
A nurse manager observes a nurse entering the room of a client who is on contact precautions without donning personal protective equipment (PPE). Which of the following is the priority action for the nurse manager to take? A. Speak with the nurse in a private location. B. Complete an incident report. C. Review competencies with the staff members regarding PPE. D. Have the nurse exit the room and don proper PPE
D. Have the nurse exit the room and don proper PPE
A nurse manager is observing the staff members working on her unit. Which of the following actions should the nurse manager recognize as an example of paternalism? A. A nurse asking to care for an older adult client every day who reminds the nurse of a favorite grandparent B. A male nurse caring for an adolescent male client because the client is uncomfortable around female nurses C. A middle-aged adult assistive personnel (AP) mentoring a younger less-experienced AP on the unit D. A nurse practitioner withholding information from a client who is dying to avoid causing the client distress
D. A nurse practitioner withholding information from a client who is dying to avoid causing the client distress
A nurse is teaching a group of older adults. Which of the following behaviors should the nurse identify as relating to Erikson's expected developmental task for this age group? A. Beginning to plan care for aging parents B. Discussing weekend plans for a date C. Initiating plans to purchase a rest home D. Accepting the possibility of the need for long-term care
D. Accepting the possibility of the need for long-term care
A nurse is caring for a client who has a dry nonproductive cough. Which of the following types of medication should the nurse recommend? A. Expectorant B. Mucolytic C. Bronchodilator D. Antitussive
D. Antitussive
A nurse is caring for a 7-year-old child who is in skeletal traction following a complete fracture of the femur. Which of the following diversional activities should the nurse offer the child? A. Puzzle with large pieces B. Building blocks C. Finger paints D. Chapter books
D. Chapter books
A community health nurse is assessing an older adult client who lives alone. Although the client is able to answer all questions appropriately, the client has a decreased attention span, expresses feelings of overwhelming sadness, and has a low energy level. The nurse should identify that the client is exhibiting manifestations of which of the following disorders? A. Delusions B. Dementia C. Delirium D. Depression
D. Depression
A nurse is caring for a client who has the head of his bed elevated to a 45° angle with his knees slightly flexed. Which of the following positions should the nurse document for the client? A. Sims' B. Prone C. Supine D. Fowler's
D. Fowler's
A nurse is reviewing the laboratory findings for 4 clients. Which of the following infections should be reported to the public health department? A. Bacterial vaginosis B. Trichomoniasis C. Candidiasis D. Gonorrhea
D. Gonorrhea
A nurse is creating a plan of care for a client who adheres to Kosher dietary laws. Which of the following food selections should the nurse recommend? A. Baked pork chop B. Cheeseburger C. Ham and cheese omelet D. Grilled salmon
D. Grilled salmon
A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing acute mania. Which of the following client goals should the nurse identify as the priority? A. Practicing problem solving skills B. Understanding the medication regimen C. Identifying indications of relapse D. Maintaining adequate hydration
D. Maintaining adequate hydration
A nurse is caring for a client who is receiving IV ampicillin and develops urticaria and dyspnea. Which of the following actions should the nurse take first? A. Elevate the client's feet and legs B. Administer epinephrine C. Infuse 0.9% sodium chloride D. Stop the medication infusion
D. Stop the medication infusion
A nurse observes tachycardia, dyspnea, a cough, and distended neck veins in a client who is receiving a transfusion of packed red blood cells (RBCs). Which of the following interventions should the nurse use to prevent these manifestations with the client's next transfusion? A. Warm the unit of blood to room temperature before administering it B. Administer acetaminophen prior to the blood transfusion C. Give an antihistamine prior to the transfusion D. Use a transfusion pump to regulate and maintain the transfusion at a slower rate
D. Use a transfusion pump to regulate and maintain the transfusion at a slower rate
A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client? A. Sweeping the floor B. Shoveling snow C. Cleaning windows D. Washing dishes
D. Washing dishes
