ATI Comprehensive Predictor 2023
screenshots actual Questions and Answers
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This section contains a list of actual 175 questions and answers for the ATI
Comprehensive Predictor 2023 from screenshots.
1. A nurse is reinforcing teaching with a postpartum client. Which of
the following should the nurse explain as the most important reason
for staff to wear identification? <u>Reducing the risk of newborn
abduction</u>
2. A nurse is reinforcing teaching with a client who plans to bottle
feed her newborn. Which of the following statements indicates an
understanding of the instructions? <u>I will feed my baby six to eight
times a day</u>
3. A nurse is reinforcing teaching with a client diagnosed with
osteoarthritis who reports joint pain, swelling, and stiffness. Which of
the following client statements indicates understanding of the
teaching? <u>I will exercise my joints as much as I can when they are
inflamed</u>
4. A nurse is reinforcing teaching with a client who is scheduled for a
mammogram. Which of the following instructions should the nurse
include in the teaching? <u>Refrain from using deodorant on the morning
of the test</u>
5. A nurse is preparing a client's insulin regimen. Which of the
following insulins can be mixed? <u>Insulin aspart, regular insulin,
insulin lispro</u>
6. A nurse is reinforcing discharge teaching with a client who is
postoperative following laser surgery for open-angle glaucoma.
Which of the following statements by the client indicates an
understanding of the instructions? <u>I will take a stool softener to
prevent constipation</u>
7. A nurse is caring for a client who had a stroke and is having
difficulty swallowing. The nurse should recommend a referral to
which of the following members of the interprofessional team?
<u>Speech therapist</u>
8. A nurse is reinforcing teaching with a client who is 12 hr
postpartum and has an episiotomy. Which of the following
instructions should the nurse include? <u>Change the perineal pad
with each void</u>
9. A nurse is collecting data from a child who has acute
Glomerulonephritis. Which of the following findings should the nurse
expect? <u>Periorbital edema</u>
10. A nurse is preparing to administer a liquid medication to a 6-
month-old infant who is crying. Which of the following actions should
the nurse take to reduce the risk of aspiration? <u>Administer using a
needless syringe in the buccal cavity</u>
11. A nurse is reinforcing teaching with a client who has peptic ulcer
disease. Which of the following statements by the client indicates an
understanding of the teaching? <u>I will plan to have my meals at
regular intervals</u>
12. A nurse in a long-term care facility has received a change-of-shift
report about four clients. Which of the following clients should the
nurse attend to first? <u>A client who has COPD and dementia and was
agitated during the night shift</u>
13. A nurse is collecting data from a client who has a substance use
disorder and reports recently taking opioids. Which of the following
findings should the nurse identify as a manifestation of opioid
intoxication? <u>Pinpoint pupils</u>
14. A nurse in an urgent care clinic is collecting data from a client
who reports having diarrhea for the past 3 days. Which of the
following findings indicates hypokalemia? <u>Muscle weakness</u>
15. A nurse is contributing to the discharge plans for four clients. The
nurse should identify that which of the following clients requires an
interdisciplinary care conference? <u>A client who has hemiparesis and
lives alone</u>
16. A nurse is reinforcing teaching with an adolescent who has a new
prescription for cefazolin. For which of the following findings should
the nurse instruct the adolescent to monitor and report to the
provider? <u>Depression</u>
17. A nurse is reinforcing teaching with a group of expectant parents
regarding the proper use of a car seat. Which of the following
statements by a parent indicates an understanding of the teaching?
<u>I can place a rolled towel on each side of my newborn's head until he
can hold his head up</u>
18. A nurse is caring for a school-age child who has epistaxis. Which
of the following actions should the nurse take? <u>Apply pressure at
the bridge of the child's nose</u>
19. A nurse is caring for four clients. Which of the following client
statements should the nurse attend to first? <u>My heartburn pain is
going into my jaw now</u>
20. A nurse in a provider's office is talking on the phone with the
parent of a school-age child who has varicella. <u>All vesicles have
crusted over</u>
21. A nurse is collecting data from a client whose Hgb is 8.8 mg/dL.
Which of the following statements should the nurse expect? <u>I feel
tired all the time</u>
22. A nurse is administering a cleansing enema to a client who
reports mild cramping during instillation of the solution. Which of the
following actions should the nurse take? <u>Slow the rate of
instillation</u>
23. A nurse receives a report on four clients. The nurse should first
collect data about the client who has which of the following? <u>A
decreased level of consciousness and vomiting</u>
24. A nurse is setting up a sterile field prior to performing a dressing
change. Which of the following actions should the nurse take?
<u>Open the outermost flap of the wrapper toward the body</u>
25. A nurse is caring for a client who has bipolar disorder and is
experiencing mania. Which of the following actions should the nurse
take? <u>Frequently remind the client of the expectations for her
behavior</u>
26. A nurse is caring for a client who has viral pneumonia. Which of
the following actions should the nurse take? <u>Administer
Azithromycin</u>
27. A nurse who is orienting to a medical-surgical unit is having
difficulty finishing client care tasks during his shift. Which of the
following suggestions should the nurse's preceptor make to help the
nurse with time management? <u>Try to complete a task before moving
on to the next.</u>
28. A nurse is caring for an older adult client who is postoperative
following a total hip arthroplasty. The nurse is preparing to change
the client's dressing. Which of the following actions should the nurse
take to demonstrate sensitivity to age-related changes? <u>Use paper
tape for securing the new dressing.</u>
29. A nurse working in an inpatient mental health facility is assisting
with the plan of care for a client who has anorexia nervosa. Which of
the following should the nurse recommend to include in the plan of
care? <u>Maintain continuity of staff members.</u>
30. A nurse is assisting with an admission interview for a client who
has schizophrenia. He tells the nurse that he is receiving special
audible messages from the Central Intelligence Agency that no one
else is able to hear. The nurse should identify that the client is having
which of the following alterations in perception? <u>Hallucination</u>
31. A nurse is reinforcing teaching with a postpartum client about
bathing her newborn. Which of the following statements should the
nurse include? <u>"Wash your newborn's head under a stream of running
water."</u>
32. A nurse is caring for a client who has heart failure and reports
difficulty limiting sodium in his diet. Which of the following
recommendations should the nurse provide? <u>Replace bottled salad
dressing with homemade vinegar and oil dressing.</u>
33. A nurse is reinforcing teaching about nonpharmacological pain
relief with a client who is 6 hr postpartum following a vaginal delivery.
The client has an episiotomy and swelling of the labia. Which of the
following instructions should the nurse include? <u>Sit on soft pillows
throughout the day.</u>
34. A nurse is caring for a client who has a new colostomy. He voices
a reluctance about resuming sexual relations. Which of the following
is an appropriate response by the nurse? <u>"I'm available if you'd like
to talk about your concerns."</u>
35. A nurse is reinforcing discharge teaching about transmission
precautions with a client who has hepatitis C. Which of the following
information should the nurse include? <u>Avoid sharing razors with
other family members.</u>
36. A nurse is reinforcing teaching about foot care with a client who
has diabetes mellitus. Which of the following client statements
indicates to the nurse a need for further teaching? <u>"I will be sure to
wear cotton socks."</u>
37. A nurse is contributing to the plan of care for a client who has
bulimia nervosa. Which of the following interventions should the
nurse recommend? <u>Observe the client for 1 hr after meals.</u>
38. A nurse is assisting with the discharge planning for a client
following a myocardial infarction. Which of the following is an
appropriate referral for this client? <u>Respiratory therapist for
breathing exercises</u>
39. A nurse is contributing to the discharge plan of an older adult
client who had a total hip arthroplasty. The client is unable to
ambulate independently and lives alone. Which of the following care
settings should the nurse recommend for this client? <u>Skilled
nursing facility</u>
40. A nurse is reinforcing teaching with the parents of a preschool-
age child who has a new diagnosis of celiac disease. Which of the
following foods should the nurse recommend? <u>Corn tortillas with
black beans</u>
41. A nurse is assisting with the admission of a client who has
mononucleosis. Which of the following isolation precautions should
the nurse initiate? <u>Droplet</u>
42. A nurse is speaking to a client who called the provider's office to
report chest pain and requests clarification on how to take his
sublingual nitroglycerin tablets. Which of the following instructions
should the nurse give the client? <u>Wait 5 min between doses.</u>
43. A nurse is caring for a client and begins to suspect he is
experiencing transference. Which of the following client statements
should the nurse identify as an indicator of transference? <u>"I feel
really close to you because you remind me of my ex-boyfriend."</u>
44. A nurse is caring for a client who has been placed in restraints.
Which of the following is appropriate? <u>Monitor the client's skin
integrity on a regular schedule.</u>
45. A nurse is caring for a client who is newly diagnosed with type 1
diabetes mellitus. The nurse should recognize that the client needs a
referral for diabetic education when the client does which of the
following? <u>States that he will treat hypoglycemic reactions with 15 g of
carbohydrates</u>
46. A nurse is preparing a client for surgery. The client tells the nurse
that he is concerned about the safety of a large sum of money in his
wallet. Which of the following actions is appropriate for the nurse to
take? <u>Contact security personnel to place the money in the facility
safe.</u>
47. A nurse on a medical-surgical unit is planning care for a group of
clients. Which of the following tasks is appropriate to delegate to an
assistive personnel? <u>Administer a large-volume enema to a
client.</u>
48. A nurse is reviewing the medical record of a client who has
sustained a full-thickness burn and is in the emergent phase of the
burn. Which of the following findings should the nurse expect?
<u>Hypercalcemia</u>
49. A nurse is collecting data from an 18-month-old toddler at a well-
child visit. Which of the following findings should the nurse report to
the provider? <u>The toddler can say four words.</u>
50. A nurse delegates a task to an assistive personnel (AP) and the
AP refuses the assigned task. Which of the following actions should
the nurse take first? <u>Perform the task.</u>
51. A nurse on a medical unit is observing an assistive personnel (AP)
delivering food trays. Which of the following actions by the AP
requires intervention? <u>Providing a ham and cheese sandwich to a
client who follows a kosher diet</u>
52. A nurse is reinforcing teaching with a client who has a vitamin C
deficiency. Which of the following foods should the nurse include as
having the highest vitamin C content? <u>1 cup raw broccoli</u>
53. A nurse is assisting with triaging clients in a mass casualty
situation. The nurse should recommend that which of the following
clients receive care first? <u>A client who has diminished breath sounds
and paradoxical chest movement</u>
54. A nurse is working in an urgent care clinic when a client who does
not speak the same language arrives with a laceration that will require
suturing. Which of the following actions is appropriate for the nurse
to take? <u>Ask an assistive personnel who speaks the same language as
the client to assist in obtaining informed consent.</u>
55. A nurse is collecting data from a client who has dehydration and
is receiving continuous IV therapy. Which of the following findings
indicates effectiveness of the IV therapy? <u>BUN 16 mg/dL</u>
56. A nurse is caring for a child who has terminal cancer. Which of the
following responses by the child's siblings should the nurse expect?
<u>The school-age sister is concerned about the impact of her sibling's
death on herself</u>
57. A nurse is caring for a client who attempted suicide. Which of the
following actions should the nurse take? <u>Serve meals with plastic
utensils.</u>
58. A nurse is removing a female client's indwelling urinary catheter.
Which of the following actions should the nurse take? <u>Withdraw
the fluid from the catheter's balloon.</u>
59. A nurse is collecting data from a parent of a preschooler at a well-
child visit. Which of the following findings is a contraindication to a
measles, mumps, and rubella (MMR) immunization? <u>Long-term use
of immunosuppressants</u>
60. A home health nurse is reinforcing teaching with a client about
kitchen safety. Which of the following instructions should the nurse
reinforce about using a fire extinguisher? <u>Sweep the extinguisher
from side to side to put out the fire.</u>
61. A nurse is caring for a client who is asking about the technique of
effleurage and its use in labor and delivery. Which of the following
responses should the nurse make regarding this technique? <u>"It is
a light stroking of the skin during a uterine contraction."</u>
62. A nurse is preparing to administer required immunizations to a
toddler during a well-child visit. The parent asks the nurse how many
baby aspirins he should administer if the toddler develops a fever.
Which of the following responses should the nurse make? <u>"You
should follow the label directions based on your child's weight."</u>
63. A nurse is caring for a client who is in mechanical restraints after
becoming violent with a staff member. Which of the following actions
should the nurse take? <u>Request that the provider write an as-needed
prescription for restraints.</u>
64. A nurse is reinforcing teaching with an older adult client who has
a new prescription for digoxin for heart failure. Which of the following
effects should the nurse include as an expected outcome of this
medication? <u>Increased heart rate</u>
65. A nurse is assisting with the plan of care for a client who has
Alzheimer's disease. Which of the following actions should the nurse
recommend for the plan of care? <u>Give directions using simple
phrases.</u>
66. A nurse is caring for a client in a provider's office. The client asks
about the purpose of a living will. Which of the following is the
appropriate response by the nurse? <u>"It expresses your wishes
regarding health care when you can no longer communicate."</u>
67. A nurse is planning to administer an ophthalmic medication to a
client. Which of the following actions will minimize systemic
absorption of the medication? <u>Wait 5 min after instillation before
instilling the drops in the other eye.</u>
68. A nurse is caring for a client who has a methicillin-resistant
Staphylococcus aureus (MRSA) infection. Which of the following
actions should the nurse plan to take? <u>Don a gown and gloves when
providing perineal care.</u>
69. A nurse is reviewing the medical record of a client who is
requesting an oral contraceptive. Which of the following findings
should the nurse identify as a contraindication to the use of oral
contraceptives? <u>History of renal calculi</u>
70. A nurse is reinforcing teaching with a client who has a new
prescription for lithium carbonate. Which of the following client
statements indicates an understanding of the teaching? <u>"I will
notify my provider if I develop a tremor."</u>
71. A nurse is caring for a client who is undergoing evaluation for a
thoracic aortic aneurysm. Which of the following findings should
make the nurse suspect an impending rupture of the aneurysm?
<u>Cough with hemoptysis</u>
72. A nurse collecting data from a client who is receiving a
continuous IV infusion of 0.9% sodium chloride. The nurse discovers
the IV infusion pump was set incorrectly and the client received 200
mL more than prescribed. Data collection reveals that the client is
stable. The nurse recognizes that this incident is not considered
malpractice for which of the following reasons? <u>The client was not
harmed as a result of the incident.</u>
73. A nurse is escorting a client to his car following discharge from an
acute mental health facility. The client states intentions to harm a
friend when he leaves the facility. Which of the following actions
should the nurse take? <u>Prevent the client from leaving the facility.</u>
74. A nurse is caring for a client who is 5 days postoperative following
abdominal surgery. The client tells the nurse that he was coughing
and "felt a pop" at the incision site. The nurse examines the incision
and finds wound dehiscence and evisceration. Which of the following
actions should the nurse take? <u>Place the client in a side-lying
position.</u>
75. A nurse is planning to reinforce teaching with a preschooler who
is about to undergo an incision and drainage for cellulitis on the left
arm. Which of the following techniques should the nurse use?
<u>Take the child on a tour of the surgery and recovery areas.</u>
76. A nurse receives a verbal order for a client to receive a stat dose
of meperidine 100 mg PO. She administers the medication, charts the
administration, and then realizes she has administered phenytoin 100
mg PO. Which of the following actions should the nurse take first?
<u>Check the client's vital signs.</u>
77. A nurse is caring for a postoperative client and obtains a pulse
oximeter reading of 89%. Which of the following interventions should
the nurse take first? <u>Repeat the test on another finger.</u>
78. A nurse is preparing to administer 5 units of regular insulin and 20
units of NPH insulin to a client who has type 1 diabetes mellitus.
Which of the following actions should the nurse take first?
<u>Withdraw 5 units of regular insulin from the vial.</u>
79. A nurse is caring for a client who has urolithiasis. Which of the
following actions should the nurse take? <u>Strain the client's
urine.</u>
80. A nurse is observing the mother of a 12-hr-old newborn. Which of
the following actions by the mother requires intervention by the
nurse? <u>The mother places the newborn in a prone position.</u>
81. A nurse in a mental health facility is reviewing the laboratory
reports for four clients. Which of the following results should the
nurse report to the provider immediately? <u>Sodium level of 130
mEq/L for a client who has bipolar disorder and takes lithium</u>
82. After receiving a change-of-shift report, which of the following
clients should the nurse collect data from first? <u>A client who has
heart failure and reports severe dyspnea</u>
83. A nurse is assisting with the admission of a client who has
Hodgkin's disease and is receiving chemotherapy. Because a private
room is not available, the nurse should recommend that the client
share a room with a client who has which of the following diagnoses?
<u>Community-acquired pneumonia</u>
84. A nurse is reinforcing teaching with a client who is about to
undergo an upper gastrointestinal series with fluoroscopy. Which of
the following information should the nurse provide? <u>"You will
receive an injection of contrast dye during the test."</u>
85. A nurse is evaluating a client who just attended a breastfeeding
class. Which of the following statements by the client demonstrates
that she has understood the teaching? <u>"I will feed my baby each
time he cries."</u>
86. A nurse is preparing morning medications for a client who has a
potassium level of 3.2 mEq/L. For which of the following medications
should the nurse withhold administration and notify the provider?
<u>Furosemide</u>
87. A nurse in a pediatric clinic is reviewing the urine laboratory
results for an adolescent. For which of the following results should
the nurse notify the provider? <u>Ketones positive</u>
88. A nurse is admitting a client who has active tuberculosis. Which of
the following nursing interventions is appropriate? <u>Place the client
in a room that is ventilated to the outside.</u>
89. A nurse is caring for a client who was recently admitted to an
inpatient mental health unit. The client tells the nurse that he is not
coming out of his room anymore because other clients on the unit
make fun of him. Which of the following responses by the nurse is
appropriate? <u>"You feel upset by the responses of others."</u>
90. A nurse is caring for a client who is receiving total parenteral
nutrition. Which of the following laboratory results indicates a
possible complication of this therapy? <u>Serum calcium 12.5
mg/dL</u>
91. A nurse in the newborn nursery is planning to obtain blood from a
newborn by a heel stick. Which of the following actions should the
nurse plan to take? <u>Apply a heat pack 5 to 10 min prior to the
procedure.</u>
92. A nurse from a medical-surgical unit is floating to a postpartum
unit. Which of the following is an appropriate assignment for the
nurse to accept? <u>A client who had a cesarean delivery 24 hr ago</u>
93. A client who is participating in an anger management session
explains that his recent behaviors are related to his job loss. Which of
the following defense mechanisms is the client using?
<u>Rationalization</u>
94. A nurse working at a crisis hotline call center receives a call from
a client who states, "I cannot take it. My life is over." Which of the
following is the priority response by the nurse? <u>Are you thinking of
harming yourself?</u>
95. A nurse is reinforcing teaching with the parents of a newborn who
had a circumcision. Which of the following client statements indicates
an understanding of the teaching? <u>"I will apply petroleum jelly to the
penis with each diaper change."</u>
96. A client's daughter calls the nurse requesting information about
her mother's condition. The client's chart does not specify that
information can be released to the daughter. Which of the following is
an appropriate response by the nurse? <u>"You will need to contact
your mother directly about her condition."</u>
97. A nurse is caring for a 17-year-old client who is admitted for an
emergency appendectomy. Which of the following is an appropriate
action by the nurse in obtaining informed consent? <u>Delay the
procedure if the provider cannot contact the parents.</u>
98. A nurse is reinforcing teaching about home care with the parents
of a child who has a seizure disorder. Which of the following
instructions should the nurse include? <u>Call EMS if a seizure lasts 5
min or more.</u>
99. A nurse in a mental health unit asks a client who has
schizophrenia, "How are you?" Which of the following responses
should the nurse identify as the speech alteration of echolalia?
<u>"How are you?"</u>
100. A nurse is reinforcing teaching with the family of a client who is
receiving palliative care for terminal cancer. Which of the following
guidelines should the nurse emphasize about appropriate pain
control measures? <u>Administer pain medication on a regular
schedule.</u>
101. A nurse in an acute mental health facility observes a client
having a panic attack. Which of the following interventions should the
nurse implement first? <u>Instruct the client to use abdominal
breathing.</u>
102. A nurse is collecting data from a 3-month-old infant who is 6 hr
postoperative following a cleft palate repair. Which of the following
pain rating tools should the nurse use? <u>FLACC scale</u>
103. A nurse is caring for a client who has a new prescription for
furosemide. The client asks the nurse about the purpose of the
medication. The nurse tells the client, "This medication is a diuretic,
and you should monitor your weight while taking it." Which of the
following ethical concepts is the nurse exhibiting? <u>Veracity</u>
104. A nurse is expressing concern about his assignment with the
charge nurse. The nurse states that he has more work to do than
anyone else. Which of the following statements by the charge nurse
demonstrates the conflict resolution strategy of competing? <u>"We
will take a look at the assignments together and attempt to modify the
workload you are concerned about."</u>
105. A nurse working on a mental health unit is meeting with a client
who has been on the unit for 2 days. The nurse greets the client and
asks, "What has been happening with you today?" Which of the
following therapeutic techniques is the nurse using? <u>Focusing</u>
106. A nurse discovers a fire in a trash can in a client's room. Which
of the following actions should the nurse take first? <u>Walk the client
to the waiting room.</u>
107. A nurse is caring for a client who is postoperative following a
femoral cardiac catheterization. Which of the following actions should
the nurse take during the first 30 min? <u>Compare the bilateral
peripheral pulses.</u>
108. A client who has inoperable cancer tells the nurse that she does
not want to pursue the recommended treatment. She asks if the
provider can force her to have the treatment. Which of the following is
an appropriate response by the nurse? <u>"You have the right to refuse
the recommended treatment plan."</u>
109. A nurse is reinforcing teaching with a client who is about to
undergo a thoracentesis. Which of the following statements by the
client indicates an understanding of the information? <u>"I will have a
chest x-ray following the procedure."</u>
110. A nurse is reinforcing teaching with a client who has a
permanent pacemaker in place. Which of the following statements by
the client indicates an understanding of the teaching? <u>"I will
remove my microwave oven from my home."</u>
111. A nurse and an assistive personnel (AP) are caring for a client
who requests a PRN pain medication. After the nurse administers the
medication, which of the following tasks should the nurse assign to
the AP? <u>Document the client's respiratory rate in 1 hr.</u>
112. A nurse is reinforcing teaching with a client who has a new
diagnosis of myasthenia gravis (MG) and a prescription for
neostigmine. Which of the following information should the nurse
include about the action of the medication? <u>Improves muscle
strength</u>
113. A nurse is assisting with the admission of an older adult client
who has impaired mobility and is at risk for falls. Which of the
following actions should the nurse plan to perform first? <u>Check the
client's ability to use the call light.</u>
114. A nurse is assisting with the admission of an older adult client.
Which of the following subjective findings suggests that the client
may have cataracts? <u>Cloudy vision</u>
115. A nurse is caring for a client who was diagnosed with
hyperemesis gravidarum. Which of the following findings should the
nurse anticipate? <u>Poor skin turgor</u>
116. A nurse is reinforcing discharge teaching with an older adult
client who has osteoarthritis. Which of the following statements by
the client indicates an understanding of the teaching? <u>"I will limit
purine intake in my diet."</u>
117. A nurse is discussing incident reports with a group of newly
licensed nurses. The nurse should include that which of the following
situations requires completion of an incident report? <u>A nurse
collects data from a client who reports severe pain and finds a dose of
hydromorphone in the client's bed.</u>
118. A nurse is reinforcing teaching with a client who has rheumatoid
arthritis and is using a straight-legged cane for ambulation. Which of
the following instructions should the nurse include? <u>"Keep the
cane on the stronger side of the body."</u>
119. A nurse is participating in a performance improvement process
to decrease the rate of health care-associated infections within the
facility. The nurse should recognize that which of the following is an
appropriate performance improvement outcome indicator? <u>Client
data indicates a decreased rate of infection.</u>
120. A nurse is contributing to the plan of care for a school-age child
who has sickle-cell disease and is experiencing a vaso-occlusive
crisis. Which of the following should the nurse recommend to include
in the plan of care? <u>Perform passive range-of-motion exercises.</u>
121. A nurse is collecting data from a client who has hepatitis A.
Which of the following findings should the nurse expect?
<u>Abdominal pain</u>
122. A nurse is reinforcing teaching about self-administration of nasal
drops with a client. Which of the following positions should the nurse
recommend for instillation of the drops? <u>Supine</u>
123. A nurse is collecting data from a client who has preeclampsia
and is receiving magnesium sulfate via a continuous IV infusion.
Which of the following findings should the nurse report to the
provider? <u>Urine output 20 mL/hr</u>
124. A nurse is orienting a newly licensed nurse to a medical-surgical
unit. Which of the following actions should the nurse take to verify
that the newly licensed nurse understands the procedure for
measuring a client's blood glucose level? <u>Have the nurse perform a
return demonstration.</u>
125. A nurse is receiving a change-of-shift report on a group of
clients. Which of the following clients should the nurse see first?
<u>A client who is exhibiting flight of ideas</u>
126. A nurse in the newborn nursery is collecting data about a
newborn's Moro reflex. Which of the following actions should the
nurse take to elicit this reflex? <u>Strike the crib surface on which the
newborn is lying.</u>
127. A nurse is caring for a client who has a new prescription for a
protective safety restraint. Which of the following actions should the
nurse take? <u>Secure the restraint with an easy-to-release tie.</u>
128. A nurse is caring for a client who has a chronic illness. In which
phase of the therapeutic relationship should the nurse help the client
develop problem-solving skills? <u>Working phase</u>
129. A nurse is monitoring a client who is receiving a blood
transfusion. Which of the following findings indicates the client is
experiencing an allergic reaction? <u>Urticaria</u>
130. A nurse is assisting in the care of a client who is experiencing a
postpartum hemorrhage. Which of the following medications should
the nurse plan to administer? <u>Methylergonovine</u>
131. A nurse is caring for an older adult client who has pneumonia.
When reinforcing teaching about the diagnosis and age-related
changes with the client's family, which of the following alterations
should the nurse include? <u>Increased elasticity of the thoracic
cage</u>
132. A nurse is collecting data from the guardian of a toddler during a
well-child visit. The guardian expresses concern to the nurse because
his child has a poor appetite, but drinks a quart of milk each day. The
nurse should identify that this practice places the toddler at risk for
which of the following conditions? <u>Lactose intolerance</u>
133. A nurse is applying a condom catheter to a male client who is
incontinent. Which of the following is an appropriate technique to
use? <u>Leave space between the tip of the penis and the end of the
condom catheter.</u>
134. A nurse is assisting in the preparation of an in-service for a
group of unit nurses about ethical principles. Which of the following
nursing actions should the nurse include as an example of fidelity?
<u>A nurse keeps a promise made to a client.</u>
135. A nurse is caring for a school-age child who is scheduled for a
bone marrow aspiration biopsy. The child asks the nurse, "Will this be
painful?" Which of the following is an appropriate response by the
nurse? <u>"There will be some pain, but I can give you medicine to make
you more comfortable."</u>
136. A nurse is assisting with the admission of a client who attempted
suicide. When the nurse processes the client's belongings, which of
the following items should the nurse remove from the client's
suitcase? <u>Perfume</u>
137. A nurse is assisting with a group therapy session in which a
client begins to monopolize the group's time. Which of the following
interventions is appropriate? <u>Schedule one-on-one discussion time
with the client.</u>
138. A nurse is caring for a client who is 3 days postoperative
following abdominal surgery and has a Penrose drain. Which of the
following actions should the nurse take? <u>Reposition the sterile
safety pin when the surgeon advances the drain.</u>
139. A nurse is caring for a toddler who is admitted to the pediatric
unit and is 2 hr postoperative following a tonsillectomy. Which of the
following findings is a sign of hemorrhage? <u>Frequent
swallowing</u>
140. A nurse in a long-term care facility is observing an assistive
personnel (AP) who is performing hand hygiene. Which of the
following actions by the AP requires intervention? <u>Holding his
hands up and elbows down while washing his hands</u>
141. A nurse is establishing a baseline postoperative assessment for
a client who is recovering from a right femoropopliteal bypass graft.
Which of the following findings in the assessment of the client's right
leg should be of the most concern to the nurse? <u>The client's pedal
pulse in the right foot is not palpable.</u>
142. A nurse is caring for a client who is experiencing chest pain. The
client states, "I am really afraid because my brother died a year ago of
a heart attack." Which of the following responses is appropriate?
<u>"This must be a frightening experience for you."</u>
143. A nurse is reviewing standard precautions with an assistive
personnel (AP) who is new to the newborn nursery. For which of the
following newborn care procedures should the nurse remind the AP
to wear clean gloves? <u>Applying an identification bracelet</u>
144. A nurse is collecting data from a client who is 1 day
postoperative following a total hip arthroplasty and has deep-vein
thrombosis. Which of the following findings should the nurse expect
in the affected extremity? <u>Dull, aching pain</u>
145. A nurse is contributing to the plan of care for a client who has
bipolar disorder and is experiencing mania. Which of the following
actions should the nurse include in the plan of care? <u>Decrease the
level of environmental stimuli.</u>
146. A nurse is caring for a client who is receiving morphine 2 mg
subcutaneously every 4 hr for pain. The medication is available in a
vial containing 10 mg/mL. How many mL should the nurse
administer? (Round the answer to the nearest tenth. Use a leading
zero if it applies. Do not use a trailing zero.) <u>0.2 mL</u>
147. A nurse is caring for a client who is receiving prazosin. The
client's blood pressure is 100/60 mm Hg. Which of the following
actions should the nurse take? <u>Instruct the client to stand up
slowly.</u>
148. A nurse is checking the home environment of a client for safety
hazards. Which of the following items require intervention by the
nurse? <u>The television set is turned to a loud volume.</u>
149. A nurse is reinforcing teaching with a client about the importance
of a low-sodium diet. Which of the following foods should the nurse
recommend as the best choice to include in a low-sodium diet? <u>1
medium baked potato</u>
150. A nurse in a prenatal clinic is reinforcing teaching with a client
about a nonstress test. Which of the following statements should the
nurse include? <u>"You will be asked to press a button when you feel
your baby move."</u>
151. A nurse is preparing to instill an otic suspension into an adult
client's ear. Which of the following methods should the nurse plan to
use? <u>Pull the auricle upward and backward.</u>
152. A nurse is reinforcing teaching about colostomy care with a
client. Which of the following client statements indicates an
understanding of how to care for the colostomy? <u>"I will empty the
colostomy bag when it is one-half full."</u>
153. A nurse is caring for a client who is postoperative following a
hemicolectomy. Which of the following is the best indication that the
client needs PRN pain medication? <u>The client reports pain.</u>
154. A charge nurse in a long-term care unit is planning care for a
group of clients. Which of the following care tasks should the nurse
plan to delegate to an assistive personnel? <u>Measuring urine output
every 2 hr for a client recently diagnosed with a urinary tract infection</u>
155. A nurse is preparing to administer cefaclor to a preschooler who
weighs 20 kg. The child is to receive cefaclor 30 mg/kg/day to divide
equally every 8 hr. Available is cefaclor suspension 125 mg/5 mL.
How many mL should the nurse administer for one dose? (Round to
the nearest whole number. Use a leading zero if it applies. Do not use
a trailing zero.) <u>8</u>
156. A nurse in a provider's office is reinforcing teaching with the
parents of a school-age child who has an active case of Pediculosis
humanus capitis. Which of the following should the nurse include in
the teaching? <u>Wash the bed linens in hot water.</u>
157. A nurse in an inpatient mental health facility is caring for a client
who has bipolar disorder and is in an acute manic episode. Which of
the following activities should the nurse suggest for the client?
<u>Take a walk with a staff member.</u>
158. A nurse is reinforcing healthy eating habits for an older adult
client to ensure adequate dietary intake. Which of the following is an
appropriate recommendation? <u>Snack between meals.</u>
159. A nurse in a provider's office is collecting data from a client who
was discharged from the hospital 7 days ago following treatment for
deep-vein thrombosis. Which of the following findings is the nurse's
priority? <u>The client takes ibuprofen daily to treat musculoskeletal
pain.</u>
160. A nurse is preparing to administer an IM injection to a client. To
reduce the risk of a needlestick injury, the nurse should take which of
the following actions? <u>Dispose of the used needle immediately in a
puncture-proof sharps container.</u>
161. A nurse is reviewing the laboratory results for a client who is at
32 weeks of gestation. For which of the following results should the
nurse notify the provider? <u>Platelet count 90,000/mm3</u>
162. A nurse is reinforcing teaching with a client who has a new
prescription for levothyroxine. Which of the following statements
indicates understanding of the instructions? <u>"I need to take this
medication for the rest of my life."</u>
163. A nurse is preparing to administer purified protein derivative
(PPD) to a client. The nurse should use which of the following routes?
<u>Intradermal</u>
164. A nurse in a clinic is reinforcing teaching with a client who has a
new prescription for a combination contraceptive transdermal patch.
Which of the following should the nurse include in the teaching?
<u>Apply the patch to the lower abdomen.</u>
165. A nurse is reinforcing teaching with a parent about appropriate
snacks for a toddler. Which of the following foods should the nurse
include? <u>Graham crackers</u>
166. A nurse is caring for a client who has COPD. The client tells the
nurse, "I get short of breath during meals. It is too much trouble to
eat." Which of the following instructions should the nurse suggest?
<u>"Have several small meals during the day."</u>
167. A nurse is caring for a school-age child whose family adheres to
a vegan diet in the home. The nurse should recognize the child is at
risk for deficiency of which of the following? <u>Vitamin D</u>
168. A nurse working in a long-term care facility is assisting with the
plan of care for a client who has Alzheimer's disease. The nurse notes
that the client wanders the halls at night and says she is looking for
the bathroom. Which of the following interventions should the nurse
recommend to include in the plan of care? <u>Label the client's
bathroom door.</u>
169. A nurse is reinforcing discharge teaching with an older adult
client's family about safety precautions when administering a tap
water enema to the client. Which of the following should the nurse
include in the instructions? <u>Instruct the client to bear down during
rectal tube insertion.</u>
170. A client who is prescribed metoprolol for hypertension tells the
nurse, "I don't want to take this medication because makes me tired
all the time." Which of the following is the appropriate response?
<u>"Let's talk with your doctor about other options."</u>
171. A nurse is preparing to catheterize a client's bladder to check for
residual urine. The nurse should schedule this procedure at which of
the following times? <u>Right after the client voids</u>
172. A nurse on a mental health unit is discussing client rights with a
group of coworkers. Which of the following statements should the
nurse include? <u>"A client must withdraw consent for treatment in writing
if he is competent to do so."</u>
173. A nurse is collecting data from a client who has diabetes
mellitus. Which of the following findings indicates the client might be
experiencing diabetic ketoacidosis? <u>Anuria</u>
174. A nurse is reinforcing teaching with the parent of a toddler who
has difficulty falling asleep. Which of the following instructions
should the nurse include? <u>Establish a bedtime routine.</u>
175. A nurse is caring for a client who is receiving warfarin 5 mg PO
daily. Which of the following laboratory values should the nurse
check prior to administering the medication? <u>PT, INR</u>
