ATI FUNDAMENTALS PROCTORED A & B 2021/2022
1.A nurse is planning to improve self­feeding for a client who has vision loss.
Which of the following interventions should the nurse include in the plan of
care?
Use a clock pattern to describe food on the client's plate.
Describing the location of food using clock pattern allows client to have greater
independence during meals.
2.A nurse is planning an education session for an older adult client who has
just learned that she has type 2 diabetes mellitus. Which of the following
strategiesshould the nurse plan to use with this client?
Allow extra time for the client to respond to questions.
Older adults often process information at slower rate than younger clients ­ allow
extra time to allow client to ask questions and absorb information
3.A nurse is caring for a client who has tuberculosis. Which of the following
actions should the nurse take? Select ALL that apply.
Place the client in a room with negative­pressure airflow ­ airborne precautions
Wear gloves when assisting the client with oral care ­ standard precautions.
Use antimicrobial sanitizer for hand hygiene ­ wash hands with soap & water when
visibly soiled.
4.A nurse is caring for a client who has a prescription for 5 units of regular insulin
and 10 units of NPH insulin to mix together and administer subcutaneously.
Determine the correct order of steps for this procedure.
Inject 10 units of air into the bottle of NPH insulin.
Inject 5 units of air into the bottle of regular insulin.
Withdraw the correct dose of regular insulin from the bottle.
Withdraw the correct dose of NPH insulin from the bottle.
5.A nurse is completing an admission assessment for a client who reports vomiting
and diarrhea for the past 3 days. Which of the following assessment findings
should the nurse expect?
Rapid heart rate
Tachycardia indicates fluid­volume deficit ­ expected
Urine specific gravity would be > 1.030
Hypotension
6.A nurse is administering IV fluid to an older adult client. The nurse should
perform which priority assessment to monitor for adverse effects?
Auscultate lung sounds.
ABCs ­ monitor for fluid­volume excess
Moist crackles in lungs, dyspnea, SOB
7.A nurse is assessing a client's readiness to learn about insulin administration.
Which of the following statements should the nurse identify as an indication that
the client is ready to learn?
"I can concentrate best in the morning."
verbalizing best time for him to learn.
8.A nurse is admitting a client who has an abdominal wound with a large
amountof purulent drainage. Which of the following types of transmission
precautions should the nurse initiate?
Contact precautions
Major wound infections require contact precautions ­ admit client to private room.
Caregivers should wear gown & gloves during direct contact.
9.A nurse is reviewing practice guidelines with a group of newly licensed nurses.
Which of the following interventions should the nurse include that is within the
RN scope of practice?
Initiate an enteral feeding through a gastrostomy tube.
Initiate feedings through nasoenteric, gastrostomy, and jejunostomy tubes.
10.A nurse is caring for a client who has a prescription for wound irrigation.
Whichof the following actions should the nurse take?
Cleanse the wound from the center outward.
Prevent introduction of micro­organisms from the outer skin surface.
11.A nurse is caring for a client who reports pain. When documenting the
quality ofthe client's pain on an initial pain assessment, the nurse should report
which of the following client statements?
"The pain is like a dull ache in my stomach."
Describing quality of pain
12.A nurse is caring for a client who is reporting difficulty falling asleep. Which
ofthe following measures should the nurse recommend?
Use progressive relaxation techniques at bedtime.
promotes sleep by decreasing stress & reducing muscle tension.
13.A nurse is caring for a client who is postoperative and refuses to use an
incentivespirometer following major abdominal surgery. Which of the following is
the nurse's priority action?
Determine the reasons why the client is refusing to use the incentive spirometer.
1st ­ Assess
14.A nurse is preparing to administer multiple medications to a client who has
anenteral feeding tube. Which of the following actions should the nurse plan to
take?
Flush the tube with 15 mL of sterile water.
Flush with 15­30 mL of sterile water before administration and between each
medication. Flush feeding tube with 30­60 mL of sterile water following
administration of last medication.
15.A nurse is caring for a client who has terminal liver cancer. Which of the
following statements should the nurse identify as an indication that the client is
experiencing spiritual distress?
"What could I have done to deserve this illness?"
Review life & question its meaning.
16.A nurse is administering an otic medication to an older adult client. Which of
thefollowing actions should the nurse take to ensure that the medication reaches
theinner ear?
Press gently on the tragus of the client's ear.
17.A nurse is performing a Romberg's test during the physical assessment of a
client. Which of the following techniques should the nurse use?
Have the client stand with her arms at her side and her feet together.
Roberg's test helps identify alterations in balance. Observe for swaying & loss of
balance.
18.A nurse is teaching an older adult client who is at risk for osteoporosis about
beginning a program of regular physical activity. Which of the following types of
activity should the nurse recommend?
Walking briskly.
Weight­bearing exercises are essential for maintaining bone mass. Walking engages
older adult clients in preventive & therapeutic strategy.
19.A charge nurse is discussing the responsibility of nurses caring for clients who
have a Clostridium difficile infection. Which of the following information should
the nurse include in the teaching?
Have family members wear a gown and gloves when visiting.
Nurses are responsible for ensuring family members wear gowns & gloves to prevent
transmission of C. diff spores.
20.A nurse is talking with a partner of an older adult male client who has
dementia.The client's partner expresses frustration about finding time to
manage household responsibilities while caring for his partner. The nurse should
identifythat he is going through which of the following types of
role­performance stress?Role overload.
Refers to having more responsibilities within a role than one person can perform.
21.A nurse is evaluating a client's use of a cane. Which of the following actions
should the nurse identify as an indication of correct use?
The client holds the can on the stronger side of her body.
Should be parallel to client's greater trochanter.
Advance cane 15­30 cm ­ 6­12 inches ­ at a time.
Move weaker leg forward with cane to divide body weight between cane & stronger
leg.
22.A nurse is caring for a client who is refusing a blood transfusion for
religiousreasons. The client's partner wants the client to have the blood
transfusion. Which of the following actions should the nurse take?
Withhold the blood transfusion.
Principle of autonomy = right to refuse treatment
23.A nurse is reviewing a client's fluid and electrolyte status. Which of the
followingfindings should the nurse report to the provider?
Potassium 5.4 mEq/L
24.A nurse is caring for a client receiving fluid through a peripheral IV
catheter.Which of the following findings at the IV site should the nurse
identify as infiltration?
Skin blanching.
Skin blanching, edema, & coolness at IV site indicate infiltration.
25.A nurse is providing care to four clients. Which of the following situations
requires the nurse to complete an incident report?
A client who has an IV infusion pump receives an additional 250 mL of IV fluid.
IV pump malfunction ­ assist in compiling information for risk management to
prevent further similar incidents.
26.A nurse manager is overseeing the care on a unit. Which of the following
situations should the nurse manager identify as a violation of HIPAA guidelines?
A nurse asks a nurse from another unit to assist with her documentation.
Only HC professionals directly caring for client may access the client's medical
information
27.A nurse is caring for a client who requires an NG tube for stomach
decompression. Which of the following actions should the nurse take when
inserting the NG tube?
Have the client take sips of water to promote insertion of the NG tube into the
esophagus.
Taking sips as NG tube passes oropharynx will close epiglottis over trachea & prevent
tube's passage into trachea.
28.A nurse is preparing a heparin infusion for a client who has hospitalized
withdeep­vein thrombosis. The order reads: 25,000 units of heparin in 250 mL
of
0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set
the infusion pump?
8 mL/hr
250mL 800 units
­­­­­­­­ X ­­­­­­­­­­­ = 8 mL/hr
25,000 units 1 hr
29.A nurse is using an open irrigation technique to irrigate a client's indwelling
urinary catheter. Which of the following actions should the nurse take?
Subtract the amount of irrigant used from the client's urine output.
Calculate fluid used for irrigation & subtract it from client's total urinary output.
30.A nurse is assessing an older adult client's risk for falls. Which of the following
assessments should the nurse use to identify the client's safety needs? Select ALL
that apply.
Pupil clarity ­ cataracts create halos around lights = cannot see items in path clearly
Visual fields ­ might not see objects outside central vision & trip over them or bump
into them & fall
Visual acuity ­ might not see objects in path & trip over them or bump into them &
fall
NOTE: Lacrimal apparatus = impaired ability to produce tears
Bulbar conjuctivae = infection in eye; does not impair vision
31.A nurse is performing a peripheral vascular assessment for a client. When
placing the bell of the stethoscope on the client's neck, she hears the following
sound. This sound indicates which of the following?
Narrowed arterial lumen.
Arterial bruits ­ blowing sound from blood flowing thru occluded or narrowed
arteries.
32.A nurse is caring for a client who has an NG tube and is receiving
intermittentfeedings through an open system. Which of the following actions
should the nurse take first?
Tell the client to keep the head of the bed elevated at least 30 degrees.
ABCs ­ prevent aspiration of enteral formula; prevent reflux of formula backward into
esophagus
33.A nurse has accepted a verbal prescription for three tenths of a milligram of
levothyroxine IV stat for a client who has myxedema coma. How should the
nurse transcribe the dosage of this medication in the client's medication record?
0.3 mg
zero precedes decimal. No zero after decimal point unless whole number follows zero.
34.A nurse is preparing a change­of­shift report. Which of the following tools or
documents should the nurse use to communicate continuity of care?
Situation, background, assessment, and recommendation (SBAR)
35.A nurse is preparing to transfer a client who has right­sided weakness from
the bed to a chair. In what order should the nurse take the following actions to
assistthe client?
Ask the client if he can bear weight. ­ Assess 1st
Position the chair on the left side of the bed. ­ stronger side
Have the client sit and dangle his feet at the bedside. ­ prevent dizziness.
Use the stand­and­pivot technique to move the client to the chair.
36.A nurse in a long­term care facility is planning to perform hygiene care for a
newresident. Which of the following assessment questions is the nurse's priority
before beginning this procedure?
"Are you able to help with your hygiene care?"
Risk of injury due to overestimation of client's ability to help with hygiene care.
1st Assess
37.A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in
a chair. To prevent self­injury, which of the following actions should the nurse
takewhen lifting this object?
Stand close to the cabinet when lifting it.
Close to center of gravity & decreases back strain from horizontal reaching.
38.A nurse is caring for a client who has had his diet prescription changed to a
mechanical soft diet. Which of the following food items should the nurse remove
from the client's breakfast tray?
Fried Egg
Not part of mechanical soft diet.
Poached or scrambled eggs are acceptable replacement.
39.A nurse is caring for a client who is expressing anger over his diagnosis of
colorectal cancer. Which of the following actions should the nurse take?
Reassure the client that this is an expected response to grief.
Anger stage of psychosocial adaptation to illness. Support client & ensure him that
this is expected reaction to cancer diagnosis.
40.A nurse is caring for a client who is terminally ill. Which of the following
statements should the nurse identify as an indication that the client's family
member is coping effectively with the situation?
"This is a difficult time, but we are helping each other through this."
Coping strategy ­ talking with others in family & supporting each other. Family using
social supports to assist them throughout grief process.
41.A nurse manager is preparing to review medication documentation with a
groupof newly licensed nurses. Which of the following statements should the
nurse manager plan to include in the teaching?
"Use the complete name of the medication magnesium sulfate."
Write complete medication name when documenting medications to avoid any
misinterpretation for morphine sulfate.
42.A nurse is caring for a client who has herpes zoster and asks the nurse about
theuse of complementary and alternative therapies for pain control. The nurse
should inform the client that his condition is a contraindication for which of the
following therapies?
Acupuncture
Contraindicated for any skin infection to prevent open portal on skin's surface =
increase risk for further infection
43.A nurse is admitting a client who has varicella. Which of the following types
oftransmission precautions should the nurse initiate?
Airborne
Varicella spreads via droplet nuclei smaller than 5 microns in diameter.
Also droplet = tuberculosis & measles
44.A nurse is giving discharge instructions to a client who will require oxygen
therapy at home. Which of the following statements should the nurse identify as
an indication that the client understands how to manage this therapy at home?
"I'll check the wires and cables on my TV to make sure they are in good working
order."
Oxygen is highly flammable gas. Electrical equipment in room with oxygen needs to
be functioning properly so it does not create electrical sparks.
45.A nurse is preparing to administer 0.5 mL of oral single­dose liquid
medicationto a client. Which of the following actions should the nurse take?
Gently shake the container of medication prior to administration.
Ensure medication is mixed.
Medication is pre­packaged into "single­dose" ­ do NOT transfer
Client should be in high­Fowler's position
46.A nurse is responding to a call light and finds a client lying on the bathroom
floor. Which of the following actions should the nurse take first?
Check the client for injuries.
Assess first
47.A nurse is assessing an adult client who has been immobile for the past 3 weeks.
The nurse should identify that which of the following findings requires further
intervention?
Erythema on pressure points
Requires prompt relief of pressure & additional measures to protect skin from further
breakdown.
48.A nurse is caring for a client who has limited mobility in his lower extremities.
Which of the following actions should the nurse take to prevent skin breakdown?
Have the client use a trapeze bar when changing position.
Assist in repositioning & transferring ­ avoids friction & shearing that result from
sliding up & down in bed.
49.A nurse is caring for a client who requires bed rest and has a prescription
forantiembolic stockings. Which of the following actions should the nurse
take? Remove the stockings at least once per shift.
Check circulation & skin integrity.
50.A nurse in a surgical suite notes documentation on a client's medical record
thathe has a latex allergy. In preparation for the client's procedure, which of the
following precautions should the nurse take?
Wrap monitoring cords with stockinette and tape then in place.
Monitoring devices & cords contain latex. Prevent contact with cords & devices with
client's skin by covering them with nonlatex barrier material ­ like stockinette, &
using nonlatex tape to secure them.
51.A nurse is reviewing protocol in preparation for suctioning secretions from
aclient who has a new tracheostomy. Which of the following actions should the
nurse plan to take?
Select a suction catheter that is half the size of the lumen.
Prevent hypoxemia & trauma to mucosa.
52.A nurse is caring for a client who asks about the purpose of advance directives.
Which of the following statements should the nurse make?
"They indicate the form of treatment a client is willing to accept in the event of a
serious illness."
Client directs treatment in event of terminal illness.
53.A nurse in a clinic is caring for a middle adult client who states, "The doctor
saysthat, since I am at an average risk for colon cancer, I should have a routine
screening. What does that involve?" Which of the following responses should the
nurse make?
"You should have a fecal occult blood test every year."
Colorectal cancer screening for clients at average risk begins at age 50. One option is
a fecal occult blood test annually.
54.A nurse is assisting a client who is postoperative with the use of an
incentivespirometer. Into which of the following positions should the nurse
place the client?
Semi­Fowler's
or high­Fowler's allows for maximum expansion of the lungs.
55.A nurse is planning to insert a peripheral IV catheter for an older adult
client.Which of the following actions should the nurse plan to take?
Place the client's arm in a dependent position.
Veins will dilate due to gravity.
56.A nurse is caring for a client who is having difficulty breathing. The client is
lying in bed with a nasal cannula delivering oxygen. Which of the following
interventions should the nurse take first?
Assist the client to an upright position.
Use the least invasive intervention. Facilitate maximal chest expansion ­ improves gas
exchange & prevents pressure on diaphragm from abdominal organs.
57.A nurse is reviewing a client's medication prescription, which reads, "digoxin
0.25 by mouth every day." Which of the following components of the
prescription should the nurse question?
The dose
Dose is not complete, number 0.25 should be followed by unit of measure to clarify
amount.
58.A nurse is assessing a client who has been on bed rest for the past month.
Whichof the following findings should the nurse identify as an indication that the
clienthas developed thrombophlebitis?
Calf swelling
Swelling, redness, & tenderness in calf muscle are manifestations of thrombophlebitis.59.
59.A nurse is caring for a client who requires a 24­hr urine collection. Which of
the following statements by the client indicates an understanding of the teaching?
"I flushed what I urinated at 7:00 am and have saved all urine since."
For a 24­hr urine collection, the client should discard the first voiding and save all
subsequent voidings.
60A nurse is preparing to administer an injection of an opioid medication to a
client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of
the following actions should the nurse take?
Ask another nurse to observe the medication wastage.
Second nurse must witness disposal of any portion of a dose of a controlled substance.6
61.A nurse receives report about a client who has 0.9% sodium chloride infusing
IVat 125 mL/hr. When the nurse performs the initial assessment, he notes that
the client has received only 80 mL over the last 2 hr. Which of the following
actions should the nurse take first?
Check the IV tubing for obstruction.
1st ­ Assess
Check tubing for obstruction ­ might be able to facilitate flow of fluid through tubing.
- could re­establish infusion rate
62.A nurse is assessing a client who reports increased pain following physical
therapy. Which of the following questions should the nurse ask when assessing
the quality of the client's pain?
"Is your pain sharp or dull?"
Ask whether pain is sharp, dull, crushing, throbbing, aching, burning, electric­like, or
shooting helps determine quality of pain.
63.A nurse is caring for a client who is postoperative. When the nurse prepares
tochange her dressing, she says, "Every time you change my bandage, it hurts
somuch." Which of the following interventions is the nurse's priority action?
Administer pain medication 45 min before changing the client's dressing.
Meet client's physiological need for comfort & pain relief. Administer analgesic 30­60
min before changing dressing.
64.A nurse is caring for a child who has a prescription for a blood transfusion.
Theparents have refused the treatment due to religious beliefs. Which of the
following actions should the nurse take?
Examine personal values about the issue.
Examine own personal values about issue to help provide care that is without bias.
65.A middle adult client tells the nurse, "I feel so useless now that my children
donot need me anymore." Which of the following responses should the nurse
make?
"People in middle adulthood often find satisfaction in nurturing and guiding young
people."
Erikson's stage ­ Generativity vs. Self­absorption & stagnation. Focus is offering
support & guidance to future generation ­ explore client opportunities for mastering
the developmental tasks of this stage ­ volunteering & mentoring young people.
66.A nurse has just inserted an NG tube for a client. Which of the following
assessment findings should the nurse expect to confirm correct tube placement?
An x­ray shows the end of the tube above the pylorus.
indicates gastric placement
67.A nurse is caring for a client who has a heart murmur. The nurse is preparing
toauscultate the pulmonary valve. Over which of the following locations should
thenurse place the bell of the stethoscope?
Second intercostal space at the left sternal border.
APE To Man
68.A nurse is providing home care for a client who is receiving tube feedings
andmedication through a gastrostomy tube. The family member providing the
feedings reports that the client has begun to have diarrhea. For which of the
following practices should the nurse intervene?
The family member washes out the feeding bag with warm water once every 24 hr.
Should wash out feeding bag at each refilling throughout the day ­ every 4­8 hr &
replace feeding bag every 24 hr to prevent bacterial contamination.
69.A nurse is providing discharge teaching to a client who has a new
prescription for a home oxygen concentrator. Which of the following
instructions should thenurse provide to the client and his family? Select ALL
that apply.
Check the cord routinely for frays or tearing.
Consider purchasing a generator for power backup. ­ power loss = concentrator not
work
Observe for signs of hypoxia ­ anxiety, worsening fatigue, dizziness, rapid pulse &
rR, pallor, & cyanosis = worsened condition
At least 10 feet away from open flames
Clothing & bedding made from material that does not generate static electricity =
cotton
70.A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to
10. Which of the following statements should the nurse identify as an indication
thatthe client understands the preoperative teaching she received about pain
management?
"It might help me to listen to music while I'm lying in bed."
Music is effective nonpharmacological intervention for management of mild pain
71.A nurse is caring for a client who has a respiratory infection. Which of the
following techniques should the nurse use when performing nasotracheal
suctioning for the client?
Apply intermittent suction when withdrawing the catheter.
prevent injury to the mucosa. Suctioning continuously for > 10 seconds can cause
cardiopulmonary compromise.
72.A nurse is caring for a client who has diarrhea due to shingella. Which of
thefollowing precautions should the nurse take?
Wash her hands before and after contact with the client.
Shingella requires nurse to perform contact precautions to prevent transmission of
bacteria.
73.A nurse on a medical­surgical unit is caring for a client who has a new
prescription for wrist restraints. Which of the following actions should the nurse
take?
Pad the client's wrist before applying the restraints.
Restraints without padding can abrade the client's skin.
74.A nurse is planning to initiate IV therapy for an older adult client who
requiresIV fluids. Which of the following actions should the nurse take?
Insert the IV catheter without using a tourniquet.
Use tourniquet minimally or not at all to avoid injury of fragile skin or veins.
75.A nurse is admitting a client who has been having frequent tonic­clonic
seizures.Which of the following actions should the nurse add to the client's plan of
care? Wrap blankets around all four sides of the bed.
pad head, foot, & sides of bed to prevent injury for client who has been having
frequent tonic­clonic seizures.
76.A nurse is caring for a client who has a terminal diagnosis and whose health is
declining. The client requests information about advance directives. Which of the
following responses should the nurse make?
"We can talk about advance directives, and I can give you some brochures about
them."
Offers to provide information the client needs in a direct & simple way.
77.A nurse is planning care for a client who has had a stroke, resulting in
aphasiaand dysphagia. Which of the following tasks should the nurse assign to
an assistive personnel (AP)? Select ALL that apply.
Assist the client with a partial bed bath.
Measure the client's BP after the nurse administers an antihypertensive medication.
Use a communication board to ask what the client wants for lunch.
Assessing swallowing ability places client at risk for aspiration. Nurses perform tasks
that require assessment.
Irrigating indwelling urinary catheter is invasive.
78.A nurse is caring for a client who has recently started using a
behind­the­ear hearing aid. Which of the following statements should the
nurse identify as anindication that she understands the use of this assistive
device?
"I will be sure to remove my hearing aid before taking a shower."
exposure to water can damage hearing aid.
79.A home health nurse who has attended a training session for the therapeutic
useof aromatherapy with essential oils is planning to use this modality with
some ofher clients. For which of the following clients should the nurse consult
the provider before using this complementary therapy?
A client who has asthma.
Some essential oils can cause bronchospasm
80.A nurse is administering 1 L of 0.9% sodium chloride to a client who is
postoperative and has fluid­volume deficit. Which of the following changes
should the nurse identify as an indication that the treatment was successful?
Decrease in heart rate
Fluid volume deficit causes tachycardia ­ correction = HR should return to expected
range.
81.A nurse is caring for a client who does not speak the same language as the
nurse.When working with the client through an interpreter, which of the
following actions should the nurse take?
Talk directly to the client, instead of the interpreter, when speaking.
speak directly to client & observe client when interpreter is translating.
82.A nurse enters a client's room and finds her on the floor. The client's
roommatereports that the client was trying to get out of bed and fell over the
bedrail ontothe floor. Which of the following statements should the nurse
document about this incident?
"Client found lying on floor."
Should include documentation that is descriptive, objective information about what
she actually observed, without any opinions or judgment about motive or cause.
83.A nurse in a provider's office is assessing the deep tendon reflexes of a client.
Which of the following images should the nurse identify as indicating the correct
technique for eliciting the client's patellar reflex?
On knee
Elicit response of lower leg extension, allow client's leg to hang freely over side of
exam table while seated & quickly tap the patellar tendon just below the kneecap
using a reflex hammer.
84.A nurse in a provider's office is obtaining the health and medication history
of aclient who has a respiratory infection. The client tells the nurse that she is
not aware of any allergies, but that she did develop a rash the last time she was
taking an antibiotic. Which of the following information should the nurse give
the client?
"We need to document the exact medication you were taking because you might be
allergic to it."
Any possibility that client had an allergic reaction ­ imperative that provider be aware
& does not prescribe same medication again. Subsequent allergic reactions could be
life­threatening.
85.A nurse is ascultating the anterior chest of a client newly admitted to a
medical­surgical unit. Listen to the audio clip of what the nurse auscultates
through his stethoscope and identify the type of breath sounds he hears.
Normal breath sounds
Normal bronchovesicular breath sounds ­ characteristically of moderate intensity and
sounding like blowing as air moves through the larger airways on inspiration &
expiration.
86.A nurse is calculating a client's fluid intake over the past 8 hr. Which of the
following items should the nurse plan to document on the client's intake and
output record as 120 mL of fluid?
8 oz of ice chips
Volume of ice chips when calculating fluid intake to account for the air in between the
chips.
8 oz ice chips = 4 oz of liquid water = 120 mL of fluid.
87.A nurse is preparing to administer enoxaparin subcutaneously to a client.
Whichof the following actions should the nurse take?
Administer the medication with the needle at a 45 degree angle.
Subcu injection at 45 or 90 degree angle.
88.A nurse is preparing to transfer a client who can bear weight on one leg from
thebed to a chair. After securing a safe environment, which of the following
actions should the nurse take next?
Assess the client for orthostatic hypotension.
1st ­ assess.
Determine client's risk for falling or fainting during transfer by assisting to sit &
dangle feet on side of bed. Assess for dizziness & significant drop in BP before
assisting to stand & transfer.
89.A nurse is caring for a client who has pharyngeal diphtheria. Which of the
following types of transmission precautions should the nurse initiate?
Droplet
Rubella, meningococcal pneumonia, and stretococcal pharyngitis
Wear mask when providing care or within 1 m ­ 3 ft of client who has disorder
requiring droplet precautions.
90.A nurse is performing a skin assessment of a client who has a lesion on his
anterior thigh and expresses concern about skin cancer. Which of the following
findings should the nurse report to the provider as a possible indication of skin
malignancy?
An uneven shape
possible indication of cutaneous malignancy ­ each half of the lesion looks different
from the other half.
91.A nurse is caring for a client who is postoperative and has signs of
hemorrhagic shock. When the nurse notifies the surgeon, he directs her to
continue to measurethe client's vital signs every 15 min and call him back in 1 hr.
From a legal perspective, which of the following actions should the nurse take
next?
Notify the nursing manager.
Greatest risk to client is not receiving intervention for deterioration in physiological
status ­ action should be is to activate the chain of command to ensure necessary care
is provided.
92.A nurse is reviewing evidence­based practice principles about administration
ofoxygen therapy with a newly licensed nurse. Which of the following actions
should the nurse include?
Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min.
EBP supports flow rate of 1­6 L/min via nasal cannula. Rates above 6 L/min force
clients to swallow air excessively without increasing their fraction of inspired oxygen.
93.A nurse is caring for a client who has a terminal illness and is approaching
death.The client's respirations are noisy from secretions in her airway and hse is
short of breath. Which of the following actions should the nurse take?
Elevate the head of the client's bed.
Promotes postural drainage and also allows maximal chest expansion, which make it
easier for client to breathe & decreases noisy respirations.
94A nurse is completing an admission assessment of an older adult client. Which
ofthe following findings should the nurse identify as a potential indication of
abuse?
Bruises in various stages of healing is an indicator of abuse. Other indicators include
burns abrasions, fractures, bite marks, dried blood, & pressure ulcers.
95A nurse is caring for a group of clients on a medical­surgical unit. In which of
thefollowing situations does the nurse demonstrate the ethical principle of
veracity? A client unaware of her recent cancer diagnosis asks the nurse if she has
cancer, and the nurse responds affirmatively.
Veracity = very truthful
Tell the truth at all times & never deceive others.
96.A nurse is caring for a client who needs to maintain a positive nitrogen
balancefor wound healing. Which of the following food items should the nurse
recommend as a good source of complete protein?
Cheddar cheese
Complete proteins contain enough of all 9 essential amino acids that help maintain &
promote nitrogen balance. Cheese, poultry, & fish are examples of good sources of
complete protein.
97.A charge nurse is observing a newly licensed nurse prepare a sterile field.
Whichof the following actions should the charge nurse identify as contaminating
the sterile field?
The nurse opens the sterile field on a wet surface.
Wet surface contaminates it because capillary action can wich bacteria through sterile
drape.
98.A nurse is giving a change­of­shift report about a client he admitted earlier
thatday who has pneumonia. Which of the following pieces of information is the
priority for the nurse to provide?
Breath sounds
ABC's ­ current status of client's breath sounds.
99.A nurse is initiating a protective environment for a client who has had an
allogeneic stem cell transplant. Which of the following precautions should the
nurse plan for this client?
Make sure the client wears a bask when outside her room if there is construction in the
area.
Allogeneic stem cell transplant compromises the client's immune system, putting her
at high risk for infection. Client will need protection from breathing in any pathogens
in the environment.
100.A nurse is caring for a client who is receiving parenteral fluid therapy via
a peripheral IV catheter. After which of the following observations should the
nurse remove the IV catheter?
Swelling and coolness are observed at the IV site.
Swelling & coolness are indications of IV infiltration, which warrant removing the
catheter and restarting the IV infusion with a new catheter at a different site.
101.A nurse is caring for a client who has an indwelling urinary catheter. Which
of the following assessment findings indicates that the catheter requires
irrigation?Bladder scan shows 525 mL of urine.
A client who has an indwelling urinary catheter should have continuous urine flow
without an accumulation of urine in the bladder. Irrigate catheter to resolve a
blockage.
102.A nurse in a long­term care facility is caring for a client who dies during
thenurse's shift. Identify the sequence in which the nurse should perform the
following steps.
Obtain the pronouncement of death from the provider.
Remove tubes and indwelling lines.
Wash the client's body.
Ask the client's family members if they would like to view the body.
Place a name tag on the body before transfer.
103.A client who is nonambulatory notifies the nurse that his trash can is on fire.
After the nurse confirms the fire, which of the following actions should the nurse
take next?
Evacuate the client.
RACE =
Rescue the clients, Activate the alarm
Confine the fire
Extinguish the fire
104.A nurse is caring for a client who is postoperative following knee
arthroplasty and requires the use of a thigh­length sequential compression
device. which ofthe following actions should the nurse take?
Make sure two fingers can fit under the sleeves.
Less space than two fingers between the sleeves and the legs can inhibit circulation
when the sleeves inflate.
105.A nurse has an order to remove sutures from a client. After retrieving the
suture remover kit and applying sterile gloves, which of the following actions
should thenurse take next?
Clean sutures along the incision site.
Greatest risk to client is injury from infection. Minimize risk of infection = clean
incision
106.A nurse is caring for a group of clients. Which of the following actions should
thenurse take to prevent the spread of infection?
Place a client who has tuberculosis in a room with negative­pressure airflow.
Tuberculosis requires airborne precautions ­ include placing client in a room that has
negative­pressure airflow to reduce risk of infection transmission.
107.A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of
thefollowing findings should the nurse expect?
Abdominal cramping
Hyponatremia = low sodium level.
Manifestations include abdominal cramping, weakness, headache, & nausea.
108.A nurse on a medical unit is preparing to discharge a client to home.
Which ofthe following actions should the nurse take as part of the medication
reconciliation process?
Compare prescriptions with medications the client received during hospitalization.
Medication reconciliation ­ create a current, accurate list of every medication the
client is or should be taking. Part of the process is comparing the medications the
client received at the facility with those the provider has prescribed for client to take
after discharge.
109.A nurse is planning care for a client who has fluid overload. Which of the
following actions should the nurse plan to take first?
Evaluate electrolytes.
1st ­ evaluate electrolytes = evaluate lab results, including sodium, potassium, BUN,
Hgb, Hct, & protein to guide planning of interventions to correct imbalances.
110.A nurse is reviewing the medical records of a client who has a pressure
ulcer.Which of the following findings should the nurse expect?
Albumin level of 3 g/dL
Indicates protein deficiency ­ placing client at risk for pressure ulcer formation & poor
wound healing.
111.A nurse is teaching a client whose left leg is in a cast about using crutches.
Whichof the following statements should the nurse identify as an indication that
the client understands the teaching?
"When descending stairs, I will first shift my weight to my right leg."
First shift body weight to unaffected leg.
112. nurse is admitting a client who is having an exacerbation of heart failure.
In planning this client's care, when should the nurse initiate discharge
planning?During the admission process.
Discharge planning should begin as soon as the client is undergoing admission. Nurse
should begin to assess the client's needs & plan for care during & after hospitalization.
113.A nurse is planning teaching for a group of adolescents who each recently had
surgical placement of an ostomy. Which of the following methods should the
nurse use as a psychomotor approach to learning?
Practice sessions
Require psychomotor skills when learning.
114.A nurse is preparing to insert an IV catheter into a client's arm prior to
initiatingIV fluid therapy. Which of the following interventions should the nurse
implement to prevent infection?
Thread the IV catheter so that the hub rests at the insertion site.
Inserting the catheter up to the hub reduces the risk of contamination along the length
of the catheter.
115.A nurse is caring for a client who has an aggressive form of prostate cancer.
Theprovider briefly discusses treatment options and leaves the client's room.
When the nurse asks if the client would like to discuss any concerns, the client
declines.Which of the following statements should the nurse make?
"I am available to talk if you should change your ind."
When a client does not wish to share his feelings with the nurse, it is important for the
nurse to convey a willingness to be available when he needs her.
116.A nurse working in the emergency department is witnessing the signing
of informed consent forms for the treatment of multiple clients during her
shift.Which of the following individuals' signatures may the nurse legally
witness?Select ALL that apply
A 16­year­old client who is married ­ minor who is married is emancipated & can
give consent for own treatment.
A 27­year­old client who has schizophrenia ­ Adult who requires psychiatric care can
gave consent for own care unless court has determined client to be incompetent.
An adoptive parent who brings in his 8­year­old son ­ adoptive parent is parent &
legal guardian & can sign consent
A 17­year­old mother who brings in her toddler ­ custodial parent who is minor can
legally give consent for medical treatment of her child.
Only a parent, legal guardian, or in emergency ­ grandparent or adult sibling, can
legally give consent for medical treatment.
117.A nurse is teaching a client about dietary management of
hypercholesterolemia.Which of the following foods should the nurse suggest that
the client add to his diet?
Avocados
Contain no cholesterol ­ plant foods contain no cholesterol
Foods from animals contain cholesterol.
118.A nurse is educating a client who has a terminal illness about her request to
decline resuscitation in her living will. The client asks what would happen if she
arrived at the emergency department and had difficulty breathing. Which of the
following responses should the nurse provide?
"We will apply oxygen through a tube in your nose."
Oxygen can provide comfort and is not resuscitative when the nurse delivers it via
nasal cannula.
119.A nurse is teaching a client and his family how to care for the client's
tracheostomy at home. Which of the following instructions should the nurse
include in the teaching?
Use tracheostomy covers when outdoors.
Tracheostomy covers protect the client's airway from cold air, dust, and other airborne
particles.
120.A nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to
infuseover 7 hr. The nurse should set the infusion pump to deliver how many
mL/hr? 107
750 mL / 7 hr = 107.14