RN ATI Capstone Proctored Comprehensive Assessment 2019 A PDF

lOMoARcPSD|13778330 Rn ati capstone proctored comprehensive assessment 2019 a latest update Comprehensive Exam (South University) RN ATI capstone proctored comprehensive assessment 2019 A 1. A nurse is teaching a client who has a new prescription for metformin extended release tablets. Which of the...

lOMoARcPSD|13778330 Rn ati capstone proctored comprehensive assessment 2019 a latest update Comprehensive Exam (South University) RN ATI capstone proctored comprehensive assessment 2019 A 1. A nurse is teaching a client who has a new prescription for metformin extended release tablets. Which of the following statements by the client indicates an understanding of the teaching? I will avoid crushing this medication I'll switch to a lactose-free formula - I will avoid crushing this medication 2. A nurse is assessing a client who is receiving enteral feeding via an NG tube. The client has developed hyperosmolar dehydration. Which of the following actions should the nurse take when administering the client's findings? Empty your ostomy pouch when it is half full Switch to a lactose-free formula. - Switch to a lactose-free formula. 3. A nurse is teaching the parents of a school-age child who has sickle cell anemia about managing the disease at home which of the following instructions should the nurse include? Apply cold compresses too painful areas I should boil tap water for 2 minutes and call it before I mix it with powdered formula - Apply cold compresses too painful areas 4. A nurse is teaching about Safe Handling of formula to a client who is postpartum and chooses to bottle feed her newborn. Which of the following statements by the client indicates an understanding of the teaching? I should boil tap water for 2 minutes before I mix it with powdered formula I should use sterile water when I mix it with powdered formula - I should boil tap water for 2 minutes before I mix it with powdered formula 5. A nurse is assessing a child who is post-operative following a tonsillectomy. Which of the following findings should the nurse identify as the priority? During this test, I will punch a button if the baby moves Frequent swallowing - Frequent swallowing 6. A nurse is teaching a client who is pregnant about non-stress testing. Which of the following statements by the client indicates an understanding of the teaching? During this test, I will punch a button if the baby moves During this test, I will punch a button if I feel stressed - During this test, I will punch a button if the baby moves 7. A nurse is monitoring a client who is receiving a transfusion of packed RBC's. The client reports chills, headaches, low back pain, and a feeling of tightness in his chest. The nurse should identify that the client has developed which of the following types of transfusion reactions? Pudendal nerve block Acute hemolytic - Acute hemolytic 8. A nurse is caring for a client who is in the latent phase of Labor and reports severe back pain. The vaginal examination reveals that the cervix is dilated two centimeters, 25% effaced and -2 station. Which of the following interventions should the nurse implement? You should wear a snug fitting bra continuously for 72 hours Request the provider prescribe a pudendal nerve block - Request the provider prescribe a pudendal nerve block 9. A nurse is teaching about how to suppress lactation with a client who is postpartum and bottle feeding her newborn. Which of the following instructions should the nurse include in the teaching? You should wear a snug fitting bra continuously for 72 hours Room number - You should wear a snug fitting bra continuously for 72 hours 10. A nurse is preparing to administer medication to a client. What are the following identifiers should the nurse use to identify the client? Room number MRN - Room number 11. A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a seated position. Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension? The clients systolic blood pressure decreases by 25 mmHg The clients systolic blood pressure increases by 35 mmHg - The clients systolic blood pressure decreases by 25 mmHg 12. While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm of the ventilator sounds. Which of the following actions should the nurse take? Look for a block in the tubes cuff Look for a leak in the tubes cuff - Look for a leak in the tubes cuff 13. A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take first? Monitor Vital Signs every hour throughout the transfusion Position the sterile drape leaving the perineum exposed - Position the sterile drape leaving the perineum exposed 14. A nurse is planning to administer packed RBC's to an older adult client who has a low hemoglobin level. Which of the following actions should the nurse plan to take? Monitor Vital Signs every hour throughout the transfusion Monitor RR every hour throughout the transfusion - Monitor Vital Signs every hour throughout the transfusion 15. A new nurse in an acute mental health facility is teaching a client about potential adverse effects of transcranial magnetic stimulation. The nurse tells the client that he might feel light-headed but that it should not affect his memory. The nurse is demonstrating which of the following ethical principles? Beneficence Restrictive - Beneficence 16. A nurse is teaching a class about providing care within the legal scope of practice to a group of nurses. The nurse should include that which of the following procedures is outside the legal scope of practice for an RN? Irrigation of the external ear canal Irrigation of the inferior ear canal - Irrigation of the external ear canal 17. A nurse in an acute care facility is caring for a client who has anorexia nervosa. During the first week of care, which of the following actions should the nurse take? Observe the client for 1 hour after meals Observe the client for 6 hours after meals - Observe the client for 1 hour after meals 18. A nurse is planning care for a client who has sciatica and a prescription for a transcutaneous electrical nerve stimulation (TENS) unit. Which of the following referral should the nurse anticipate for the client? Primary Care Provider Physical therapist - Physical therapist 19. A nurse is teaching a client who has generalized anxiety disorder about ways to help manage stress. Which of the following instructions should the nurse give the client about using Progressive relaxation? Tighten the muscle group, then release tension and move to the next one Rest the muscle group, then release tension and move to the next one - Tighten the muscle group, then release tension and move to the next one 20. A nurse is assessing a client who is at 37 weeks of gestation and reports sudden, severe abdominal pain with moderate vaginal bleeding and persistent uterine contraction. The client's blood pressure is 88 over 50 mmhg and her abdomen is rigid. The nurse should identify these findings as indicating which of the following complications? Placenta discharge Placenta abruption - Placenta abruption 21. A home health nurse is planning care for an older adult client who has a vision loss and takes medication throughout the day. Which of the following actions should the nurse include in the plan? Use container Lids of different shapes to indicate times of Administration Use container Lids of different colors to indicate times of Administration - Use container Lids of different shapes to indicate times of Administration 22. A nurse at an acute care facility is teaching a client about fall risk prevention strategies for use during their stay at the facility. Which of the following statements by the client indicates an understanding of the teaching? I will wear a yellow wristband, so everyone knows I'm at risk for falling I will wear call for help, so everyone knows I'm at risk for falling - I will wear a yellow wristband, so everyone knows I'm at risk for falling 23. A nurse is caring for a client who is taking disulfiram for alcohol-use disorder and reports ingestion of alcohol. For which of the following adverse effects should the nurse monitor? Headache Hypertension - Headache 24. A nurse at the health department is providing anticipatory guidance to a parent of a one month or a year-old infant. The nurse should inform the parent that the infant should receive which of the following immunizations at the age of two months? C. Diff Rotavirus - Rotavirus 25. A Nurse is assisting in the selection of foods for a client who has dysphagia caused by a stroke. Which of the following foods should the nurse recommend? Scrambled eggs Fish - Scrambled eggs 26. A community health nurse is providing education to a group of older adults about immunizations. Which of the following immunizations should the nurse recommend? Tdap HIV - Tdap 27. A nurse is caring for a client who is postoperative following a mitral balloon valvuloplasty. Which of the following areas should the nurse auscultate to assess for mitral areas of the heart? (you will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) See picture - Mitral 28. A nurse is planning care for a client who is experiencing benzodiazepine toxicity. The nurse should plan to administer which of the following medications? Flumazenil Furosemide - Flumazenil 29. A nurse is admitting a client to the medical-surgical unit. The patient self-determination act requires the nurse to perform which of the following actions during the admission process? Document in the client's medical record if a client has advance directives Document in the client's medical record if a client has PCP directives - Document in the client's medical record if a client has advance directives 30. A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an indication of paralytic Ileus? Abdominal dissection Abdominal distension - Abdominal distension 31. A nurse is performing an administered admission assessment of a school-age child who has spina bifida. the parents state that a child is allergic to latex. The nurse should assess further for cross sensitivity to which of the following Foods? Tomatoes Bananas - Bananas 32. A nurse is planning care for a client who is at 32 weeks of gestation and has severe preeclampsia. Which of the following actions should the nurse plan to take? Ensure that the bed is flat Ensure that the side rails are up on the client's bed - Ensure that the side rails are up on the client's bed 33. A nurse is documenting admission data for a client in an acute care facility. Which of the following actions should the nurse take? Clarify medical issue with PCP Note whether the client has a living will - Note whether the client has a living will 34. A client on an acute mental health unit states to a nurse, tie a bow. Row the boat. Now I know. Whoa! I see you. The nurse should document that the client is exhibiting which of the following speech alterations? Stress Association Clang Association - Clang Association 35. A nurse is caring for a client who has Crohn's disease. The nurse calculates that the client BMI is 17.2. The nurse should document that the clients wait status is being within which of the following categories? Normal weight Underweight - Underweight 36. A nurse is planning post-operative care for a client who is scheduled for a thoracotomy with chest tube placement. Which of the following pieces of equipment should the nurse plan to have at the client's bedside? Tracheostomy tray Bedside commode - Tracheostomy tray 37. A nurse is providing discharge teaching to a client who has Gerd. Which of the following information should the nurse include? Avoid consuming foods containing potassium Avoid consuming foods containing chocolate - Avoid consuming foods containing chocolate 38. A nurse is part of a task force planning to audit a facilities nursing unit concerning adherence to hand hygiene protocols. Which of the following steps should the task force take first? Determine the accepted standards for hand hygiene Determine the accepted standards for ambulation - Determine the accepted standards for hand hygiene 39. A nurse is planning educational materials for a client who has a new pacemaker. Which of the following information should a nurse include? Keep mobile phones 4 inches from the pacemaker generator Keep mobile phones 6 inches from the pacemaker generator - Keep mobile phones 4 inches from the pacemaker generator 40. A nurse is providing discharge teaching to a client who is 1-day postoperative following a right modified radical mastectomy. Which of the following instructions should the nurse include in the teaching? Avoid using the affected arm for eating Explain how early ambulation is recommended - Avoid using the affected arm for eating 41. A nurse is planning care for a client prior to an amniocentesis. Which of the following actions should the nurse include in the plan of care? Monitor the fetal heart rate throughout the procedure Monitor the patients LOC throughout the procedure - Monitor the fetal heart rate throughout the procedure 42. A nurse is assessing a 24-month-old toddler at a well-child checkup. Which of the following findings indicates to the nurse that the toddler has a developmental delay? Runs with a wide stance Runs with a bi-lateral stance - Runs with a wide stance 43. A nurse is caring for a client following an involuntary admission to an acute mental health facility. The client states, I'm afraid they will give me drugs that put me to sleep. Which of the following statements should the nurse make? What medication's have you previously taken to help you sleep? Why do you think your provider will prescribe you medication's that will make you sleep? - Why do you think your provider will prescribe you medication's that will make you sleep? 44. A nurse in an emergency department is administering naloxone to a client who had a heroin overdose. The nurse should identify which of the following assessment findings as an indication that the medication is reversing the effects of the opioid overdose? Increased respiratory rate Decreased respiratory rate - Increased respiratory rate 45. A nurse is caring for a client who is preoperative for cataract removal. Which of the following statements by the client indicates an understanding of the procedure? I can expect my eyelids to be bruised after this procedure I can expect my eyelids to be swollen after this procedure - I can expect my eyelids to be bruised after this procedure 46. A nurse is planning care for a client who is undergoing brachytherapy for a low dose radiation implant for treatment of prostate cancer. Which of the following interventions should the nurse include in the client's plan of care? Encourage each of the client's visitors to stay 4-6 hours per day Limit each of the client's visitors to two hours per day - Limit each of the client's visitors to two hours per day 47. A nurse is teaching a client about using transdermal scopolamine to treat motion sickness. Which of the following instructions should the nurse include? Apply the patch prior to traveling Apply the patch at the same location - Apply the patch prior to traveling 48. A nurse is admitting a school-age child who has bacterial meningitis. Which of the following types of isolation precautions should the nurse initiate? Droplet Contact - Droplet 49. A nurse is planning assignments for an upcoming shift. Which of the following tasks should the nurse delegate to an assistive Personnel? (select all that apply.) Record a client's intake after each meal Transfer a client to physical therapy Obtain the client's vital signs every 4 hours Notify PCP client's morning weight - Record a client's intake after each meal Transfer a client to physical therapy Obtain the client's vital signs every 4 hours 50. A nurse is interpreting a cardiac Rhythm strip from a client who has recurrent episodes of syncope. Which of the following images indicates the client has atrial fibrillation? First Rhythm Second Rhythm - First Rhythm (Second Rhythm is Atrial Flutter) 51. A community health nurse is planning an educational program on Lyme disease or the general public. Which of the following statements should the nurse include in the program? Remove embedded Ticks by squeezing the body with tweezers Remove embedded Ticks by squeezing the body with light pressure - Remove embedded Ticks by squeezing the body with tweezers 52. A nurse is admitting a client to the medical-surgical unit. The patient self-determination act requires the nurse inform which of the following actions during the admission process? Document in the client's medical records if the client has advance directives Document in the client's medical records if the client has living will - Document in the client's medical records if the client has advance directives 53. A nurse is teaching a client how to care for his behind the ear hearing aid. Which of the following statements by the client indicates an understanding of the teaching? I'll disconnect the battery when I remove my hearing aids I'll lower the sound level of my hearing aids at night - I'll disconnect the battery when I remove my hearing aids 54. A nurse is caring for a client who is postpartum and expresses concern about how her preschool-age son will react to having a baby sister. Which of the following strategies should the nurse suggest? Wait to introduce his new sister until he asks Give your son a little gift from his new sister - Give your son a little gift from his new sister 55. A nurse is teaching a class about using niacin to reduce LDL cholesterol. The nurse should include in the teaching that which of the following conditions is a contraindication for receiving this medication? Active liver disease Acute kidney disease - Active liver disease 56. A school nurse is using the Weber test to check a child. Which of the following actions should the nurse take? Place a vibrating tuning fork on the tips of the child's toes Place a vibrating tuning fork on the top of the child's head - Place a vibrating tuning fork on the top of the child's head 57. A nurse is reviewing the medical record of a client who has a prescription for misoprostol for induction of Labor. Which of the following findings is a contraindication for administration of this medication? Inverse fetal lie Transverse fetal lie - Transverse fetal lie 58. A nurse is reviewing the results of laboratory screenings for a nine-month-old infant. Which of the following results should the nurse report to the provider? Iron 74 mcg /dL Calcium 9 mg/dL - Iron 74 mcg / dL. 59. A nurse is teaching a client who has a new prescription for sertraline to treat depression. For which of the following findings should the nurse instruct the client to Monitor and Report immediately as indicating serotonin syndrome? Excessive sweating Dry skin - Excessive sweating 60. A community health nurse is developing a plan of care for an older adult client who has Type 2 diabetes mellitus and lives independently in a rural area. Which of the following interventions should the nurse include? Instruct the client about the use of Telehealth services Instruct the client about the use of direct family services - Instruct the client about the use of Telehealth services 61. A nurse in a provider's office is monitoring the laboratory results of a client who has type 1 diabetes mellitus. Which of the following results and the case of the client demonstrates acceptable glycemic control? Hba1c 6.8% Hba1c 22% - Hba1c 6.8% 62. A nurse is providing dietary teaching to the guardian of a preschooler who has celiac disease. Which of the following foods should the nurse recommend including the preschoolers' diet? A corn tortilla with black beans Low-protein powder - A corn tortilla with black beans 63. A nurse is caring for a client who has a peritoneal catheter that requires a dressing change. Identify the sequence of actions the nurse should take. (the steps into the box on the right, placing them in the order of the performance. Using all the steps.) Remove the old dressing Cleanse the site with povidone-iodine Mask self and the client Apply precut gauze pads to the site Create a sterile field - 1st- Mask self and the client 2nd- Remove the old dressing 3rd- Create a sterile field 4th- Cleanse the site with povidone-iodine 5th- Apply precut gauze pads to the site 64. A case manager is performing a home visit for a client following a stroke. The client's partner is providing care in the home. The client's partner states that she sometimes feels exhausted. For which of the following referral should the case manager recommend for the caregiver? Despite care Respite care - Respite care 65. A nurse is reviewing the laboratory results of a client who is receiving Total parenteral Nutrition. Which of the following results should the nurse identify as an identification for the client has developed a common complication of this nutritional therapy? Capillary glucose 198 mg / DL Capillary glucose 35 mg / DL - Capillary glucose 198 mg / DL 66. A nurse is teaching a newly licensed nurse about advance directives. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? Patient can resume control of health care after a temporary loss of competency Patient needs to control health care before a temporary loss of competency - Patient can resume control of health care after a temporary loss of competency 67. A nurse is assessing a client for an allergy spider administering the Influenza vaccine. The nurse should identify that an allergy to which of the following Foods is a contraindication to receiving this vaccine? Eggs Meat - Eggs 68. A nurse is caring for a client who has deep vein thrombosis and a new prescription for an anti-embolic stocking. Which of the following actions should the nurse take? Measure the legs with a tape measure to determine stocking size Measure the feet with a tape measure to determine stocking size - Measure the legs with a tape measure to determine stocking size 69. A nurse is inserting a short peripheral IV catheter for a client who is requires IV fluids. Which of the following actions should the nurse take? Select a site proximal to previous venipuncture sites Select a site distal to previous venipuncture sites - Select a site proximal to previous venipuncture sites 70. A charge nurse is evaluating a newly licensed nurse who is caring for a client who has measles. Which of the following actions by the newly licensed nurse should the charge nurse intervene? The nurse wears an N95 respirator when performing client care The nurse wears a gown when performing client care - The nurse wears a gown when performing client care 71. A nurse is caring for a client who is 2 days postpartum. Which of the following findings should the nurse report to the provider? 1 + deep tendon reflexes 4 + deep tendon reflexes - 4 + deep tendon reflexes 72. A nurse is observing an assistive Personnel (AP) measure blood pressure from the right arms of the group of clients. The nurse should instruct the AP to measure the blood pressure in the left arm of which of the following clients? A client who had dialysis and is using an arteriovenous shunt in the left upper arm A client who had dialysis and is using an arteriovenous shunt in the left lower forearm - A client who had dialysis and is using an arteriovenous shunt in the left lower forearm 73. A nurse is caring for a female client who requires bed rest and reports difficulty urinating into a bedpan. Which of the following actions should the nurse take? Turn on the faucet in the client's sink Turn off the faucet in the client's sink - Turn on the faucet in the client's sink 74. A charge nurse observes smoke coming from a trash receptacle and the units waiting room. Which of the following actions should the nurse take first? Call code emergency Evacuate clients from the area - Evacuate clients from the area 75. A nurse is caring for a client who has diabetic ketoacidosis. During the shift, the client receives 0.45% sodium chloride IV at 500 mL over hours for 3 hours. Then at 200 mL/ hour for 3 hours. And then dextrose 5% in water at 75 mL / hour for 2 hours. What is the total volume the nurse should document for the client's IV fluid intake? (round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) - 1250_mL 76. A nurse is teaching a client who is at 20 weeks of gestation about how to manage Harbor. Which of the following instructions should the nurse include? Eat a high-carb snack in the morning Eat a high-fiber snack at bedtime - Eat a high-fiber snack at bedtime 77. A nurse is assessing a client who is taking Digoxin to treat chronic heart failure. Which of the following findings should indicate to the nurse that the client is developing Digoxin toxicity? Blurred vision Productive cough - Blurred vision 78. A charge nurse is observing an assistive Personnel perform delegated tasks. Which of the following actions by the AP requires a charge nurse to intervene? Washing hands with alcohol-based hand rub after bathing a client who has c-diff Washing hands with sterile hand rub after bathing a client who has c-diff - Washing hands with alcohol-based hand rub after bathing a client who has c-diff 79. A nurse is caring for four children in an emergency department. Which of the following clients should the nurse assess first? A child who has acute epiglottitis and is drooling A child who has acute epiglottitis and is crying loudly - A child who has acute epiglottitis and is drooling 80. A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a kidney transplant. Which of the following findings should the nurse report? Serum creatinine 1.6 mg/dL Serum creatinine 1.01 mg/dL - Serum creatinine 1.6 mg/dL 81. A nurse is providing discharge instructions about a newborn safety to a client who is 2 days postpartum. Which of the following instructions should the nurse include? Use a car seat when traveling by airplane. No traveling by airplane. - Use a car seat when traveling by airplane. 82. A nurse is caring for a client who has major depressive disorder. The client tells the nurse, "No one cares about me. I'm completely alone". Which of the following responses should the nurse make? "Can you give me an example of how others are making you feel this way?" "Tell me why others are making you feel this way" - "Can you give me an example of how others are making you feel this way?" 83. A nurse on a medical-surgical unit is caring for a client who states that she plans to leave the facility against medical advice. For which of the following actions by the nurse should the charge nurse intervene? - Asks security to detain the client until the provider is notified 84. A nurse is providing prenatal teaching to a client who is at 12 weeks of gestation. The nurse should tell the client she will undergo which of the following screening tests at 16 weeks of gestation? Maternal serum alpha-fetoprotein Maternal serum potassium - Maternal serum alpha-fetoprotein 85. A nurse is admitting a client who has schizophrenia and experiences occasional auditory hallucinations. The client states, "It's hard not to listen to the voices." Which of the following questions should the nurse ask the client? "Do you understand that the voices are not real?" "Why do you think these voices are talking to you?" - "Do you understand that the voices are not real?" 86. A nurse is planning care for a client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse include to support the client's nutritional requirements? Maintain protein intake at 1,500 per day Maintain calorie intake at 1,500 per day - Maintain calorie intake at 1,500 per day 87. A charge nurse is preparing to lead negotiations among nursing staff due to a conflict about overtime requirements. Which of the following strategies should the charge nurse use to promote effective negotiation? Attempt to understand both sides of the issue Separate clients - Attempt to understand both sides of the issue 88. A nurse is preparing to administer a NG tube feeding to a school-age child. Which of the following actions should the nurse plan to take? Measure the tubing from the nose to the distal port Measure the tubing from the nose to the proximal port - Measure the tubing from the nose to the distal port 89. A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? Monitor the FHR via Doppler every 10 min Monitor the FHR via Doppler every 30 min - Monitor the FHR via Doppler every 30 min 90. A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first? Report to provider Measure the client's vital signs - Measure the client's vital signs 91. A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include? Excessive sweating Anger - Excessive sweating 92. A nurse is caring for a client who is postoperative and has a chest tube drainage system. For which of the following findings should the nurse notify the provider? Tidaling occurs when the client is breathing Bi-daling occurs when the client is breathing - Tidaling occurs when the client is breathing 93. A nurse is preparing to administer vancomycin IV to an adult. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make? "I can't start the medication any earlier." "I can start the medication 15 min earlier." - "I can start the medication 30 min earlier." 94. A nurse in the emergency department is interviewing a client immediately following a sexual assault. Which of the following actions should the nurse take first? Determine a client's current stress level Determine a client's current anxiety level - Determine a client's current anxiety level 95. A nurse is caring for a client who has gestational hypertension and is experiencing toxic effects due to magnesium sulfate therapy. The nurse should anticipate administering which of the following medications? Furosemide Calcium gluconate - Calcium gluconate 96. A nurse is caring for a client who has end-stage kidney disease. The client's adult child asks the nurse about becoming a living kidney donor for their parent. Which of the following conditions in the child's medical history should the nurse identify as a contraindication to the procedure? Hypertension Oliguria - Hypertension 97. A nurse has identified tasks to delegate to a group of assistive personnel (AP) after receiving change-of-shift report. Identify the sequence of steps the nurse should follow when delegating tasks to the Aps. Put in order Review the skill level and qualifications of each AO Monitor progress of tasks completion with each AP Evaluate the APs' performance of each task Communicate appropriate tasks to the APs with specific expectations - 1st Review the skill level and qualifications of each AO 3rd Monitor progress of tasks completion with each AP 4th Evaluate the APs' performance of each task 2nd Communicate appropriate tasks to the APs with specific expectations 98. A nurse is preparing to perform sterile wound irrigation and dressing change for a client. Which of the following actions by the nurse indicates a break in surgical aseptic technique? Balancing the bottle on the sterile basin while pouring the liquid Balancing the bottle on the sterile basin while draining the liquid - Balancing the bottle on the sterile basin while pouring the liquid 99. A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? "We should establish our roles in the initial session." "We should establish our roles in the next session." - "We should establish our roles in the initial session." 100. A nurse is caring for a client who is receiving intermittent enteral tube feeding. Which of the following factors places the client at risk for aspiration? A history of gastroesophageal reflux disease A history of kidney disease - A history of gastroesophageal reflux disease 101. A nurse is caring for a client who is 4 hr postpartum. The client reports an urge to void but is unable to void. Which of the following actions should the nurse take? Encourage the client to attempt to void while using a Sitz bath Encourage the client not to void while using a Sitz bath - Encourage the client to attempt to void while using a Sitz bath 102. A nurse is caring for a client who has preeclampsia and is experiencing a postpartum hemorrhage. The nurse should expect the provider to prescribe which of the following medications? Oxytocin Oxycodone - Oxytocin 103. A nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse include in the teaching? "This test should be performed after your baby is 2 months old." "This test should be performed after your baby is 24 hours old." - "This test should be performed after your baby is 24 hours old." 104. A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching? Documenting communication with a provider in the progress notes of the client's medical record Documenting communication with previous nurses in the progress notes of the client's medical record - Documenting communication with a provider in the progress notes of the client's medical record 105. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse assess first? A client who has a hip fracture and a new onset of severe pain A client who has a hip fracture and a new onset of tachypnea - A client who has a hip fracture and a new onset of tachypnea 106. A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan to take? Secure the urinary catheter to the client's thigh Secure the urinary catheter to the client's lower back - Secure the urinary catheter to the client's thigh 107. A nurse is planning care for a group of clients. Which of the following methods should the nurse use to manage time effectively? Gather supplies prior to completing a dressing change Call nurses for help prior to completing a dressing change - Gather supplies prior to completing a dressing change 108. A nurse is preparing to assist the provider with a paracentesis for a client who has ascites. Which of the following actions should the nurse plan to take? Have the client wait to void until after the procedure Have the client void prior to the procedure - Have the client void prior to the procedure 109. A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching? "I can visit my nephew who has chickenpox 5 days after the sores have crusted." "I can visit my nephew who has chickenpox 2 weeks after the sores have crusted." - "I can visit my nephew who has chickenpox 5 days after the sores have crusted." 110. A nurse is caring for a school-age child who has sickle cell anemia and is in vasoocclusive crisis. Which of the following actions should the nurse take? Increase oral fluid intake Decrease oral fluid intake - Increase oral fluid intake 111. A nurse is assessing a client who is 2 hr postpartum for uterine atony. Which of the following actions should the nurse take? Palpate the client's fundus Palpate the client's dorsalis - Palpate the client's fundus 112. A nurse manager is reviewing documentation with a newly licensed nurse. Which of the following notations by the newly licensed nurse indicate an understanding of the teaching? "OOB with assistance for breakfast." "OOB with assistance for voiding." - "OOB with assistance for breakfast." 113. A charge nurse is teaching new staff members about factors that increase a client's risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence? Previous violent behavior Previous hallucinations - Previous violent behavior 114. A nurse is teaching a wellness class about depression for a group of older adult clients. Which of the following information should the nurse include in the teaching? Depression can be misdiagnosed as an abnormal disorder in older adult clients Depression can be misdiagnosed as a neurocognitive disorder in older adult clients - Depression can be misdiagnosed as a neurocognitive disorder in older adult clients 115. A nurse is assessing a client who is receiving morphine IV for pain. Which of the following findings should the nurse report the provider first? BP 143/92 mm Hg BP 80/40 mm Hg - BP 80/40 mm Hg 116. A nurse is providing discharge teaching to a client who is postoperative following surgery for carpal tunnel syndrome. Which of the following statements by the client indicated an understanding of the teaching? "I should not use my affected hand for 2 to 4 weeks." "I should not use my affected hand for 4 to 6 weeks." - "I should not use my affected hand for 4 to 6 weeks." 117. A nurse is using an IV pump for a newly admitted client. Which of the following actions should the nurse take? Check the cords of the IV pump for fraying Check the cords of the IV pump for blocking - Check the cords of the IV pump for fraying 118. A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan? Place the clients left arm on a pillow while he is sitting Place both arms on a pillow while he is sitting - Place the clients left arm on a pillow while he is sitting 119. A nurse on a pediatric unit is preparing to insert an IV catheter for a 7-year-old child who is dehydrated. Which of the following actions should the nurse take? Tell the child there will be discomfort during the catheter insertion Tell the child there will be nausea during the catheter insertion - Tell the child there will be discomfort during the catheter insertion 120. A nurse is caring for a client who has acute glomerulonephritis. The nurse should identify that which of the following findings is the priority? BUN 24 mg/dL BUN 19 mg/dL - BUN 24 mg/dL 121. A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is the priority for the nurse to report to the provider? Hypotension SOB - Hypotension 122. A nurse is reviewing the medical record of a client. Which of the following findings should the nurse report to the provider? Temperature Vision change - Temperature 123. A nurse in the infectious disease division of the local health department is caring for a client. Which of the following infections should be reported to the health department? Chlamydia trachomatis Multiple myeloma - Chlamydia trachomatis 124. A nurse in a family practice clinic is screening an adolescent client for idiopathic scoliosis. Which of the following assessments should the nurse perform as part of this screening? Measure the peripheral rotation Measure the truncal rotation - Measure the truncal rotation 125. A nurse is assessing an older adult client who had left-sided stroke. Which of the following findings should the nurse expect? Expressive aphasia Depressive aphasia - Expressive aphasia 126. A nurse is preparing to teach the parents of a child who has cystic fibrosis. Which of the following instructions should the nurse plan to include? Provide a diet high in protein and calories Provide a diet high in protein and carbs - Provide a diet high in protein and calories 127. A nurse is reviewing the medical records of four clients. The nurse should identify which of the following client findings requires follow-up care? A client who received a Mantoux test 2 hr ago and has an induration A client who received a Mantoux test 48 hr ago and has an induration - A client who received a Mantoux test 48 hr ago and has an induration 128. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include? Consume foods high in bran fiber Consume foods high in bran iron - Consume foods high in bran fiber 129. A nurse is planning care for a client who has an L4 spinal cord injury. Which of the following interventions to prevent skin breakdown should the nurse include in the plan of car? Ask the client to shift his weight every 20 min while sitting in a chair Ask the client to shift his weight every few hours while sitting in a chair - Ask the client to shift his weight every 20 min while sitting in a chair 130. A nurse is caring for a client who has bipolar disorder and is experiencing acute manifestations. The nurse obtained verbal prescription for mechanical restraints. Which of the following actions should the nurse take? Assess the clients peripheral pulse rate every 2 hours Assess the clients peripheral pulse rate every 30 min - Assess the clients peripheral pulse rate every 30 min 131. A nurse is teaching a guardian of an adolescent who has mild persistent asthma and a new prescription for maintenance prednisone. Which of the following statements by the guardian indicated an understanding of the teaching? "This medication can decrease my son's risk for infection "This medication can increase my son's risk for infection - "This medication can increase my son's risk for infection 132. A charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following examples should the charge nurse include in the teaching? Keeping the side-rails of a toddler's crib elevated Keeping the side-rails of a toddler's crib locked - Keeping the side-rails of a toddler's crib elevated 133. A nurse is reviewing assessment data from several clients. For which of the following clients should the nurse recommend referral to a dietician? A client who has a nonhealing leg ulcer A client who has a progressive leg ulcer - A client who has a on a nonhealing leg ulcer 134. A nurse is assessing a client who is 1 day postoperative following the placement of an ileostomy. Which of the following findings should the nurse report to the provider? The stoma has a purplish hue The stoma has a reddish hue - The stoma has a purplish hue 135. A nurse is caring for a client who is obese. The client is crying and states, "Everyone is staring at me because of my weight." Which of the following responses should the nurse make? "Have you always felt uncomfortable being overweight?" "Have you ever talked about being overweight?" - "Have you always felt uncomfortable being overweight?" 136. A nurse is preparing educational material for a client. Which of the following techniques should the nurse use in creating the material? Write information at a seventh-grade reading level Write information at a fifth grade reading level - Write information at a seventh-grade reading level 137. A nurse is caring for a client who has a new prescription for warfarin. When reviewing the client's current medication, which of the following medications should the nurse identify as contraindicated for use with warfarin? (Select All That Apply) Ibuprofen Gingko biloba Aspirin Heparin - Ibuprofen Gingko biloba Aspirin 138. A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching? Eat 2g/kg of protein per day Eat 1g/kg of protein per day - Eat 1g/kg of protein per day 139. A nurse is performing gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following actions should the nurse take? Insert a small-bore NG tube Insert a large-bore NG tube - Insert a large-bore NG tube 140. A nurse is reading a tuberculin skin test for a client who received a purified protein derivative test 72 hr ago. Which of the following findings indicates a positive test? An induration measuring 5 mm An induration measuring 10 mm - An induration measuring 5 mm 141. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor which of the following complications? Contractions Decreased Contractions - Contractions 142. A nurse is reviewing the medication administration record of a client. Which of the following prescriptions should the nurse clarify? Digoxin.250 PO daily Digoxin 1.250 IV daily - Digoxin.250 PO daily 143. A nurse is caring for a client who is at 38 weeks of gestation, is in active labor, and has ruptured membranes. Which of the following actions should the nurse take? Apply a fetal glucose monitor Apply a fetal heart rate monitor - Apply a fetal heart rate monitor 144. A nurse is assessing a client who is receiving daily aspirin therapy. The nurse should identify that which of the following findings might indicate an allergic reaction to this medication? Difficulty coughing Difficulty swallowing - Difficulty swallowing 145. A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine? WBC count 20,000/ mm3 WBC count 2,900/ mm3 - WBC count 2,900/ mm3 146. A nurse is providing teaching about crutch safety to a client. Which of the following client actions indicated an understanding of the teaching? The client places the crutches 30 cm (12 in) to the front and side of each foot while standing The client places the crutches 60 cm (12 in) to the front and side of each foot while standing - The client places the crutches 30 cm (12 in) to the front and side of each foot while standing 147. A nurse is teaching a newly licensed nurse about incident reports. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? "They assist with unit quality improvement." "They assist with unit discussion improvement." - "They assist with unit quality improvement." 148. A nurse is providing dietary teaching to a client who has chronic kidney disease. Which of the following instructions should the nurse include? Restrict foods containing magnesium Restrict foods containing phosphorus - Restrict foods containing phosphorus 149. A nurse is caring for a group of clients who have chronic pain. Which of the following clients should the nurse identify as a candidate for occupational therapy? A client who has painful hands due to degenerative joint disease A client who has painful muscles due to degenerative joint disease - A client who has painful hands due to degenerative joint disease 150. A nurse is teaching a client who has chronic urinary tract infection. Which of the following instructions should the nurse include? Drink at least 1 L of fluid everyday Drink at least 4 L of fluid everyday - Drink at least 1 L of fluid everyday 151. A nurse is speaking with the partner of a client who is the early stage of Alzheimer's disease. The partner tells the nurse that she is able to manage the client's physical care, but she doesn't want to leave him alone while she travels for work. Which of the following referrals should the nurse make? Respite care Cardiate care - Respite care 152. A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching? "Have your child drink a small glass of water after swallowing the medication." "Have your child drink a small glass of water before and after swallowing the medication." - "Have your child drink a small glass of water after swallowing the medication." 153. A nurse is caring for a client who is recovering from an amputation of her right arm below the elbow. Which of the following information should the nurse report to the occupational therapist? The client has no family support at home The client has two small children at home - The client has two small children at home 154. A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first? Palpate the pulse proximal to the cast Palpate the pulse distal to the cast - Palpate the pulse distal to the cast 155. A nurse is preparing to assist with the lumbar puncture of an infant. The nurse should plan to place the infant in which of the following positions? Flexed side lying Flexed supine lying - Flexed side lying 156. A newly licensed nurse is unsure if an assigned task is within their scope of practice. Which of the following resources should the nurse consult? Local Nurse Practice Act State Nurse Practice Act - State Nurse Practice Act 157. A nurse is caring for client who is experiencing a diazepam overdose. Which of the following medications should the nurse administer? Flumazenil Digoxin - Flumazenil 158. A community health nurse is reviewing laboratory reports for a group of clients. The nurse should identify that which of following disorder is on the CDC's Nationally Notifiable Conditions list? Lyme disease Ulcerative colitis - Lyme disease 159. A nurse manger is developing a protocol for staff discipline. Which of the following actions should the nurse manger take when implementing this new protocol? Inform client about the purpose of the unit's new processes. Inform staff about the purpose of the unit's new processes. - Inform staff about the purpose of the unit's new processes. 160. A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods while taking this medication? Whole grain bread Fried meats - Whole grain bread 161. A nurse is administering a continuous enteral feeding to a client. Which of the following actions should the nurse Take? Return aspirate residuals 300 mL or less. Return aspirate residuals 600 mL or less. - Return aspirate residuals 300 mL or less. 162. A nurse in an urgent care clinic is caring for infant who presents with vomiting, diarrhea, and decreased oral intake. Which of the following manifestations should the nurse expect? Oliguria Polyuria - Oliguria 163. A nurse is teaching a newly licensed nurse about postpartum hemorrhage. Which of the following statements by the new licensed nurse indicates an understanding of the teaching? "Postpartum hemorrhage can occur within the first 6 weeks after delivery." "Postpartum hemorrhage can occur within the first week after delivery." - "Postpartum hemorrhage can occur within the first 6 weeks after delivery." 164. A Nurse Manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include? Document the client's condition every 15 min. Document the client's condition every 2 hours. - Document the client's condition every 15 min. 165. A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? Perform the procedure prior to meals Perform the procedure after meals - Perform the procedure prior to meals 166. A nurse on medical-surgical unit is performing medication reconciliation for newly admitted client. Which of the following actions should the nurse take? Compare the client's list of home medications to the admission prescriptions written for the client. Review the client's list of prescriptions written for the client. - Compare the client's list of home medications to the admission prescriptions written for the client. 167. A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? "The client exhibits impulsive behavior." "The client exhibits erratic behavior." - "The client exhibits impulsive behavior." 168. A nurse is teaching a client who is pregnant and has a new prescription for an iron supplement. Which of the following statements should the nurse include? "You might experience diarrhea while taking this medication." "You might become constipated while taking this medication." - "You might become constipated while taking this medication." 169. A nurse is caring for a client who has cancer of the throat findings and is receiving radiation therapy. The nurse should monitor for which of the following findings as an adverse effect of the radiation? Altered taste sensation Altered smell sensation - Altered taste sensation 170. A nurse is caring for client who is febrile. To reduce the client's fever, the nurse applies a cooling blanket. Which of the following findings indicates the client is having an adverse reaction to the cooling"? Sweating Shivering - Shivering *Maybe restlessness 171. A nurse is caring for an infant who has respiratory syncytial virus. Which of the following interventions should the nurse take? Suction nares prior to feeding Suction nares after feeding - Suction nares prior to feeding 172. A nurse is caring for a client who is wearing anti-embolic stockings. Which of the following interventions should the nurse include in the plan of care? Fold the top of the stockings over neatly Fold the top of the stockings over tightly - Fold the top of the stockings over neatly 173. A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a kidney transplant. Which of the following findings should the nurse report? Serum creatinine 1.6 mg/dL Urine pH 6.2 BUN 18 mg/dL - Serum creatinine 1.6 mg/dL 174. A nurse is reviewing the laboratory report of a client who has been receiving lithium carbonate for the past 12 months. The nurse note lithium carbonate level of 0.8 mEQ/L. Which of the following orders from the provider should the nurse expect? Administer the medications Discontinue the medication - Administer the medications. 175. A nurse is preparing discharge information for a client who has type 2 diabetes mellitus. Which of the following resources should the nurse provide to the client? Diabetes medication information from the Physicians' Desk Reference Food exchange lists for meal planning from the American Diabetes Association - Food exchange lists for meal planning from the American Diabetes Association 176. A nurse is teaching a group of clients at community health fair about genetic risks for disease. Which of the following statements by a client indicates an understanding of the teaching? "My family has genetic risk for breast cancer, so I am considering a total mastectomy". "Even if I have a genetic risk for a disease, the chance I will get the disease is probably low due to current medical treatments". - "My family has genetic risk for breast cancer, so I am considering a total mastectomy". 177. A nurse in a surgical clinic is providing teaching to a client who is scheduled for a modified radical mastectomy. Which of the following statements by a client indicates an understanding of the teaching? "I will complete my arm exercises four times a day." "I can shower within 48 hours of my surgery." - "I will complete my arm exercises four times a day." 178. A nurse is assessing a client who had an uncomplicated vaginal birth 3 days ago. In which of the following locations should the nurse expect to palpate the client's fundus? (See Picture) A B C -C 179. A nurse is caring for an infant who has coaction of the aorta. Which of the following should the nurse identify as an expected finding? Weak femoral pulses Frequent nosebleeds - Weak femoral pulses 180. A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make? "Eat foods that are high in sodium" "Rise slowly when getting out of bed" - "Rise slowly when getting out of bed" 181. A nurse is assisting with food selection for client who follows kosher dietary traditions. Which of the following food choices should the nurse include on the client's food try? Scrambled eggs and toast with milk Ham sandwich with milk - Scrambled eggs and toast with milk *Clients who adhere to a kosher diet can eat dairy products combined with non-meat products at the same meal. 182. A nurse is caring for a client who has chronic kidney failure and serum potassium level of 6.8 mEq/L. Which of the following actions should the nurse take first? Give sodium sulfonate to the client Prepare the client for hemodialysis - Prepare the client for hemodialysis 183. A nurse is transcribing new medication prescriptions for a group of client. For which of the following prescriptions should the nurse contact the provider for clarifications? Triamcinolone acetonide 100 mcg/inhalation two puffs TID Lorazepam.5mg PO one tablet daily - Lorazepam.5mg PO one tablet daily 184. A nurse is reviewing the medication administration record of a client who has benign prostatic hyperplasia (BPH). The client asks the nurse about taking saw palmetto. The nurse should instruct the client that which of the following medications interacts adversely with saw palmetto? Clopidogrel Penicillin - Clopidogrel 185. A nurse is caring for client who is at 11 weeks of gestation. Which of the following immunizations should the nurse recommend? Influenza Varicella - Influenza 186. A nurse is providing teaching to a client who is on glucocorticoid therapy. Which of the following statements by the client indicates an understanding of the teaching? "I have my eyes examined annually" "I take a calcium vitamin supplement daily" - "I take a calcium vitamin supplement daily" 187. A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan? Ask the client directly what he is hearing Encourage the client to lie down in a quiet room - Ask the client directly what he is hearing 188. A nurse is caring for a client who has schizophrenia and is experiencing delusions. Which of the following actions should the nurse take? Direct long conversations about the delusions toward reality-based topics. Avoid assessing client's delusions - Direct long conversations about the delusions toward reality-based topics. 189. A staff nurse is observing a newly licensed nurse suction a client's tracheostomy. Which of the following requires intervention by the staff nurse? Waits 2 minutes between suctions. Encourages the client to cough during suctioning. - Waits 2 minutes between suctions. 190. A nurse is preparing to perform a heel stick on an infant. Which of the following actions should the nurse plan to take to reduce the infant's pain during the procedure? Provide the infant with a bottle of water during the procedure Promote skin to skin contact with infant's guardian during the procedure - Promote skin to skin contact with infant's guardian during the procedure 191. A nurse is teaching participants at a community center about advance directives. Which of the following information should the nurse include in the teaching? A client must create a do-not-resuscitate order when completing advance directives. Advance directives cannot be changed once implemented. - A client must create a do-not-resuscitate order when completing advance directives. 192. A nurse is assessing a newborn 2 hr following birth. Which of the following findings should the nurse expect? Heart Rate 190/min Irregular respirations - Heart Rate 190/min 193. A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan? Encourage the client to spend time in the day room Encourage the client to take frequent rest periods - Encourage the client to take frequent rest periods 194. A nurse is flushing a client's intermittent infusion device. The client's states. "Why do you have to do that if you are not giving me medicine?" Which of the following statements should the nurse make? "This prevents leakage of fluid and medication." This clears blood from the tubing and the catheter." - This clears blood from the tubing and the catheter." 195. A nurse is creating a plan of care for a newly admitted client who has obsessivecompulsive disorder. Which of the following interventions should the nurse include? Discourage the client from exploring irrational fears Allow the client enough time to perform rituals - Discourage the client from exploring irrational fears 196. A director of nursing in rehabilitation facility is planning to measure the quality of care provided. Which of the following audits should the Director plan to use after clients are discharged to gather information about quality of care? Concurrent audit Outcome Audit - Outcome Audit 197. A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the following clients should the nurse see first? A client who has preeclampsia and reports a persistent headache A client who has pregestational diabetes mellitus and an HbA1c of 6.2% - A client who has preeclampsia and reports a persistent headache 198. A nurse on mental health unit is planning room assignments for four clients. Which of the following clients should the nurse assign to a room near the nurses' station? A client who has bipolar disorder and impaired social interactions A client who has depressive disorder and reports feeling hopeless - A client who has depressive disorder and reports feeling hopeless 199. A nurse is teaching about preventing sudden infant syndrome (SIDS) to parent of a 1-month-old infant. Which of the following indicates that the parent understands how to place the infant in the crib at bed time? (See picture) A B C D -B 200. A nurse is caring for a 1-month old infant who has manifestation of severe dehydration and prescription for parenteral fluid therapy. The guide lines asks, "What are the indications that my baby needs an IV?" Which of the following responses should the nurse make? "Your baby needs an IV because she is breathing slower than normal." "Your baby needs an IV because she is not producing tears." - "Your baby needs an IV because she is not producing tears." 201. A nurse is assessing a client who is pregnant and has a new diagnosis for hyperemesis gravidarum. Which of the following findings should the nurse expect? Urine output 20 mL/hr Distended neck veins - Urine output 20 mL/hr 202. A nurse is caring for an infant who has respiratory syncytial virus. Which of the following interventions should the nurse take? Initiate neutropenic precautions Administer palivizumab intravenously - Initiate neutropenic precautions 203. A nurse is teaching a client who is receiving radiation therapy about skin protection. Which of the following client statements indicates an understanding of the teaching? "I will apply my favorite unscented lotion to the irradiated area of skin twice each day "I will make sure I have sterile water to wash the irradiated area of skin." - "I will apply my favorite unscented lotion to the irradiated area of skin twice each day 204. A nurse is caring for a client who has left-sided heart failure, and the provider is concerned that the client might develop (Unable to read) Which of the following actions should the nurse take? Place the client's lower extremities on two pillows. Place the client in high fowler's position. - Place the client in high fowler's position. 205. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? Stay in bed at least 1hr if unable to fall asleep Eat a light snack before bedtime - Eat a light snack before bedtime 206. A nurse is teaching a client who has heart failure about engaging in an exercise program. Which of the following statements by the client indicates an understanding of the teaching? "I will slow my walking pace of I experience chest pain." "I will work to achieve 60 minutes of exercise each day." - "I will work to achieve 60 minutes of exercise each day." 207. A nurse is caring for a client who experienced a traumatic brain injury 72 hr. ago. Which of the following findings should the nurse identify as an indication of intercranial pressure? Hypotension. Increasingly severe headache. - Increasingly severe headache. 208. A nurse is performing an abdominal assessment as part of a client's comprehensive physical examination. Which of the following is the final step the nurse should perform? Palpation Percussion Auscultation Inspection - Palpation 209. A nurse is caring for a 1-day-old newborns who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take? Keep the infants head covered with a cap. Ensure that the newborn wears a diaper - Ensure that the newborn wears a diaper 210. A nurse is caring for a client who received a transfusion of 250 mL of packed RBCs. The nurse should identify that which of the following findings indicates the client is responding positively to the transfusion? The clients lung sounds remain clear during the transfusion The clients hemoglobin level increases following the transfusion - The clients hemoglobin level increases following the transfusion 211. A nurse in the PACU is caring for a client who reports nausea. Which of the following actions should the nurse take first? Turn the client on their side. Administer antiemetic - Turn the client on their side. 212. A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? Bleeding gums Faintness upon rising - Bleeding gums 213. A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? A client who has COPD and a respiratory rate of 44/min A client who has cancer with a sealed implant for radiation therapy - A client who has cancer with a sealed implant for radiation therapy 214. A nurse is caring for a client who is in active labor and noted the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia? Maternal hypoglycemia Maternal fever - Maternal hypoglycemia 215. A nurse is caring for a client who has a major burn injury. Which of the following actions is the nurse's priority to prevent wound infection? Apply topical antibiotics to the client's wounds Use sterile dressings for wound care - Use sterile dressings for wound care 216. A nurse overhears two assistive personnel (AP) discussing care for a client while in the elevator. Which of the following actions should the nurse take? Notify the client's provider about the incident Report the incident to the AP's charge nurse - Report the incident to the AP's charge nurse 217. A nurse is preparing to obtain a client's signature on an informed consent form. Which of the following actions should the nurse take first? Ask the client to explain his understanding of the procedure Inform the client of his right to change his mind - Ask the client to explain his understanding of the procedure 218. A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider? Temperature 37.4 C (99 F) Contractions lasting 80 seconds - Contractions lasting 80 seconds 219. A nurse in an emergency department is caring for a client who has a closed head injury. Which of the following actions should the nurse take first? Administer mannitol IV bolus to the client Determine the clients Glasgow Coma Scale score - Determine the clients Glasgow Coma Scale score 220. A home health nurse is preparing to make an initial visit to a family following a referral from a local provider. Identify the sequence of steps the nurse should take when conducting a home visit. Put in order Contact the family to determine availability and readiness to make an appointment Clarify the reason for the referral with the provider's office Record information about the home visit according to agency policy Discuss plans for future visits with the family Identify family needs and interventions using the nursing process - Clarify the reason for the referral with the provider's office Record information about the home visit according to agency policy Contact the family to determine availability and readiness to make an appointment Identify family needs and interventions using the nursing process Discuss plans for future visits with the family 221. A nurse is providing discharge teaching to a client who has type 1 diabetes mellitus about preventing diabetic ketoacidosis when ill. Which of the following statements by the client indicated an understanding of the teaching? "I will not give myself insulin when I am sick." "If I am sick, I will check my blood sugar twice a day." - "If I am sick, I will check my blood sugar twice a day." 222. A nurse is caring for a client who has respiratory depression from an opioid administration. After administering naloxone to the client, which of the following findings should the nurse expect? Hyperglycemia Increased pain - Increased pain 223. A nurse is caring for a client who reports insomnia. Which of the following findings is priority for the nurse to report the provider? Takes 15-min naps four to five times per day Seems depressed and irritable - Seems depressed and irritable 224. A newly licensed nurse is reviewing the role of a nurse in disaster planning. Which of the following is an activity a nurse should engage in to assist in disaster preparedness? Participate in community drills and mock events Assess types, levels, and scopes of disasters - Participate in community drills and mock events 225. A nurse is planning care for a client who is receiving hemodialysis. Which of the following actions should the nurse include in the plan of care? Rehydrate with dextrose 5% in water for orthostatic hypotension Check the vascular access site for bleeding after dialysis - Rehydrate with dextrose 5% in water for orthostatic hypotension 226. A nurse is caring for a client who has heart failure. For which of the following laboratory values should the nurse withhold the client morning dose of digoxin and contact the provider? Potassium 3.2 mEq/L Calcium 9.2 mg/L - Potassium 3.2 mEq/L 227. A nurse working in a health department is conducting a health screening for a group of farmworkers. Which of the following client statements indicates a possible health risk? "My home has running water and electricity." "I wear a hat and long sleeves while I am working." "I am currently sharing my home with two roommates." "I eat vegetables directly from the field where I work." - "I am currently sharing my home with two roommates." 228. A nurse is assessing a client who is currently taking furosemide. Which of the following reports by the client indicates a manifestation of an adverse effect of this medication? Weight gain Increased urinary output - Weight gain 229. A nurse is reviewing laboratory findings for a client who is receiving total parental nutrition. For which of the following findings should the nurse notify the provider? Random glucose 120 mg/dL Sodium 125 mEq/L - Sodium 125 mEq/L 230. A nurse is assessing a client coccyx area for a pressure ulcer. The nurse notes that superficial subcutaneous fat is visible and tunneling is present. Which of the following pressure ulcer stages should the nurse document? Stage IV Unstageable Stage III Stage II - Stage III 231. A nurse in a mental health facility is caring for a client who is experiencing a panic level of anxiety. Which of the following actions should the nurse take? Use short sentences when communicating with the client Encourage the client to talk about his feelings - Use short sentences when communicating with the client 232. A nurse in an intensive care unit is assessing a client who has heart failure and has been receiving metoprolol for 3 days. Which of the following indicates the treatment has been effective? Increased heart rate Decreased edema - Decreased edema 233. A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include? "This type of seizure can be mistaken for daydreaming." "This type of seizure lasts 30 to 60 seconds." - "This type of seizure can be mistaken for daydreaming." 234. A nurse is reviewing home recommendations with a client who is postoperative following knee surgery. Which of the following recommendations should the nurse make? Place a handrail in the entryway of the house Wear slippers with cloth soles - Place a handrail in the entryway of the house 235. A nurse is caring for a client who is 12 hr postoperative following a transurethral resection of the prostate. Which of the following findings should the nurse report to the provider? Urgency to void Report of pain level of 5 on a scale of 0 to 10 - Urgency to void 236. A nurse is assessing a school-age child who has a urinary tract infection. Which of the following findings should the nurse expect? Enuresis Periorbital edema - Enuresis