Test Mode Assessment

No.

1 :
A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client indicates an understanding of this technique?

"I think about my grandfather's farm to reduce pain.”

"I listen to my favorite music to take my mind off the pain.”

"I use focused breathing to control my pain.”

"I learn to notice the sensation of muscle tension.”

Hint : 🧠 Visualization calms pain

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

2 :
A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations can the nurse disclose health information without the client's written consent?

To an employer for a pre-employment screening.

To a family member when the client is not available.

To a medical interpreter service on behalf of a client.

To an insurance agency in regard to a life insurance policy.

Hint : 🗣️ Interpreter supports treatment

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

3 :
A home health nurse is visiting a client who has advanced Alzheimer's disease. The client's partner states, "I miss being able to go places with my friends.”. Which of the following is an appropriate response by the nurse?

"We can discuss this when you're not feeling overwhelmed.”

"Have you tried taking your partner with you when you go out?"

"Tell me more about your expectations.”

"I understand how you feel. I've had a relative go through the same thing.”

Hint : 🧓 Explore caregiver emotions

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

4 :
A nurse is recording the intake and output (I&O) for a client. The client consumed 8 oz of milk, 10 oz of water, 4 oz of gelatin, 1 egg, 1 piece of bacon, and 2 biscuits. Which volume should the nurse record on the I&O?

Hint : 🧃 Only fluids count

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

5 :
A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification band. Which of the following actions should the nurse take to verify the client's identity?

Review the client's photograph in the medical record.

Request an assistive personnel to identify the client.

Ask the client to state their room number.

Have the client state their phone number.

Hint : 🖼️ Photo confirms identity

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

6 :
A nurse is participating in a group discussion about complicated grief associated with loss. Which of the following should the nurse identify as an example of exaggerated grief?

A client whose grief response is repressed.

A client whose grief response begins following a terminal diagnosis.

A client whose grief response leads to self-destructive behaviors.

A client whose grief response is triggered by a secondary loss.

Hint : 🕯️ Harmful coping = exaggerated

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

7 :
A nurse is observing an assistive personnel (AP) apply a belt restraint to a client. Which of the following actions by the AP requires intervention by the nurse?

Using a quick-release tie to secure the restraint.

Tying the restraint to the bed frame.

Placing the restraint across the client's chest.

Applying the restraint over the client's gown.

Hint : ⚠️ Chest = breathing risk

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

8 :
A charge nurse is observing a newly licensed nurse who is caring for a group of clients. Which of the following statements by the newly licensed nurse indicates an understanding of infection control principles?

"I will use disinfectant to clean the blood pressure cuff after use on a client.”

"I will double-bag a client's linens each day.”

"I will wear sterile gloves when bathing a client who is incontinent.”

"I will rinse the contaminants from a bedpan with hot water.”

Hint : 🧼 Disinfect shared equipment

Correct Answers:

No Correct Answers Available !

Rationale :

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9 :
A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps?

Unlock and remove the inner cannula.
Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
Scrub the inside and outside of the inner cannula with a small brush.
Wipe the inside of the inner cannula with a folded pipe cleaner.
Cleanse the stoma site with 0.9% sodium chloride solution.

Hint : 🫁 Sterile steps = clean airway

Correct Order:

No correct order available !

Rationale :

Rationale to be Available Soon

10 :
A nurse is reinforcing teaching with a client about how to collect a stool specimen. Which of the following instructions should the nurse include?

Avoid placing toilet tissue in the bedpan after defecation.

Urinate after the specimen collection

Place 1.3 cm (0.5 in) of formed stool into a culture tube.

Keep the specimen in a warm area.

Hint : 💩 No tissue in sample

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

11 :
A nurse is assisting in the transfer of a client who has left-sided weakness from a bed to a chair. Which of the following actions should the nurse take?

Flex hips and knees when assisting the client to a standing position.

Pivot on the foot farthest from the bed when assisting the client into the chair.

Stand on the client's stronger side when moving the client into the chair.

Raise the bed to waist level before moving the client.

Hint : 🚶‍♂️ Support stronger side

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

12 :
A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit. Which of the following actions should the nurse include in the plan?

Restrict the number of visitors for clients.

Turn on loud music in client care areas.

Offer the clients many choices regarding care.

Assign different nurses to provide care for clients each day.

Hint : 🔇 Limit noise and traffic

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

13 :
A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, "I'm not going to take this medication because it makes me sick and dizzy.”. Which of the following actions should the nurse take first?

Document the refusal in the client's medical record.

Return the medication to the medication cabinet.

Inform the client of the potential consequences of their refusal.

Notify the provider of the client's refusal.

Hint : 📞 Call provider first

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

14 :
A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

Inject air into the ampule prior to drawing the medication into a syringe.

Add 0.5 mL of diluent to the medication.

Use a filter needle to aspirate the medication.

Cleanse the tip of the ampule with an alcohol swab after opening.

Hint : 💉 Filter before draw-up

Correct Answers:

No Correct Answers Available !

Rationale :

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15 :
A nurse is preparing to administer sucralfate 80 mg/kg/day to divide into four doses per day to a child who weighs 35 kg. The amount available is sucralfate oral suspension 1 g/10 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 7

Hint : 🧪 Weight-based mg/kg dose

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

16 :
A nurse is reinforcing teaching with an older adult client who has urinary incontinence. Which of the following instructions should the nurse include?

Drink citrus juice with meals.

Train the bladder by voiding every 5 hours.

Apply adult diapers at bedtime.

Perform pelvic-muscle exercises.

Hint : 🧘 Kegels strengthen control

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

17 :
A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

Inject air into the ampule prior to drawing the medication into a syringe.

Add 0.5 mL of diluent to the medication.

Use a filter needle to aspirate the medication.

Cleanse the tip of the ampule with an alcohol swab after opening

Hint : 🧴 Filter protects from glass

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

18 :
A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client's room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?

Administer a sedative medication to the client.

Explain to the client that they cannot leave until the surgeon discharges them.

Have the client sign an against medical advice form.

Tell the client that the surgeon will prescribe restraints if they try to leave.

Hint : 📝 Use AMA documentation

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

19 :
A nurse on a medical-surgical unit receives a telephone call from an individual who identifies himself as the client's employer. The employer asks the nurse about the client's condition. Which of the following is an appropriate response by the nurse?

"The client's condition is stable right now.”

"I will tell him you called.”

"I cannot confirm or deny that we have a client by that name.”

"He is here in the hospital, but I cannot tell you anything else.”

Hint : 🔐 HIPAA protects identity

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

20 :
A nurse is reinforcing teaching with a client about blood glucose monitoring. The client becomes quiet and appears distracted while the nurse is providing the instructions. Which of the following responses should the nurse make?

"Let's talk about what you're thinking.”

"Is this something you think you can do?"

"Are you feeling okay?"

"Do you need more time to absorb this information?"

Hint : 🧠 Explore emotional readiness

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

21 :
A nurse is caring for an older adult client who has fecal incontinence. Which of the following actions should the nurse take?

Apply cornstarch powder to the perineal area.

Turn the client every 4 hours.

Cleanse the perineal area with povidone-iodine solution.

Place a moisture barrier ointment over the perineal area.

Hint : 🧴 Protect skin from moisture

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

22 :
A home health nurse is reinforcing teaching about dietary needs with the child of a client. They state, "I don't know what to do because they're not eating.”. Which of the following responses should the nurse make?

"Tell me more about what happens at mealtime.”

"They may need a feeding tube.”

"Have you tried offering different foods?"

"Let's discuss ways to encourage their appetite.”

Hint : 🍽️ Explore mealtime behavior

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

23 :
A nurse is assisting with scoliosis screenings for students at a public school. Which of the following findings should the nurse recognize as an indication of scoliosis?

Unequal height of the shoulders.

Increased concave curve of the thoracic spine.

Expansion of the upper intercostal spaces.

Increased convex curve of the cervical spine.

Hint : 🦴 Look for uneven shoulders

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

24 :
A nurse is setting up a sterile field in a client's room. Which of the following actions should the nurse take?

Placing the cap of a sterile solution on a clean surface with the inside facing down.

Placing a sterile instrument within 1.3 cm (0.5 in) of the edge of the sterile field.

Opening the top flap of the sterile tray package away from their body.

Dropping sterile objects onto the field from a height of 5 cm (2 in).

Hint : 🧼 Open flap away first

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

25 :
A nurse is reinforcing teaching with a client who is perimenopausal. Which of the following statements by the client indicates an understanding of the teaching?

"I might have headaches due to a decline in my estrogen levels.”

"I should stop receiving Papanicolaou tests once I reach menopause.”

"I can expect to have regular periods until I am in menopause.”

"The best time to perform a breast self-examination is on the first day of my period.”

Hint : ♀️ Estrogen levels affect symptoms

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

26 :
A nurse is caring for a client who had an indwelling urinary catheter inserted 3 days ago. Which of the following actions should the nurse take?

Use a catheter securing device to hold the catheter in place.

Obtain urine from the drainage bag if a urinary specimen is required.

Change the catheter bag every 3 days and as needed.

Position the drainage bag higher than the client's bladder.

Hint : 🛡️ Secure catheter to protect

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

27 :
A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days.Which of the following laboratory findings should the nurse expect?

Hypermagnesemia.

Hyperkalemia.

Hyponatremia.

Hypocalcemia

Hint : 🧂 Sodium drops with diarrhea

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

28 :
A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Assess the pain level of a client who has received acetaminophen.

Check a client's peripheral IV site for redness or swelling.

Measure the intake and output of a client who has received furosemide.

Reinforce teaching with a client about crutch-gait walking.

Hint : 💧 APs can track fluids

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

29 :
A nurse is showing a newly licensed nurse how to use a mechanical lift.Which of the following statements by the newly licensed nurse indicates an understanding of this assistive device?

"The sides of the sling are for the client to hold on to.”

"This type of device is useful for a client who cannot assist.”

"The lower end of the sling goes below the client's calves.”

"The device requires the client to use upper body strength.”

Hint : 🦾 Use for total assistance

Correct Answers:

No Correct Answers Available !

Rationale :

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30 :
A nurse is delegating client care to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Administering vaginal cream to a client who has a vaginal infection.

Providing postmortem care for a client who has just died.

Suctioning a tracheostomy for a client who has a recent head injury.

Changing a peripheral IV dressing for a client who is postoperative.

Hint : 🕊️ APs can do postmortem

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

31 :
A nurse in a long-term care facility is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

Apply suction while inserting the catheter.

Apply intermittent suction for up to 30 seconds.

Preoxygenate the client prior to suctioning.

Instruct the client to swallow during catheter insertion.

Hint : 🫁 Oxygen before suctioning

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

32 :
A nurse is caring for an older adult client who has a hearing aid. Which of the following actions should the nurse take when the client reports hearing a whistling sound from the hearing aid?

Clean the hearing aid with isopropyl alcohol.

Turn the hearing aid off for 5 minutes.

Soak the hearing aid in warm water.

Decrease the volume on the hearing aid.

Hint : 🎧 Lower volume reduces feedback

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

33 :
. A nurse is reinforcing teaching about end-of-life care with the partner of a client. Which of the following statements should the nurse make?

"Encourage your partner to eat three large meals each day.”

"Opioids will be restricted if your partner develops respiratory distress.”

"We will use an electric blanket to keep your partner warm.”

"Assume your partner can hear you, even if they do not respond.”

Hint : 🕯️ Talk to unresponsive patients

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

34 :
A nurse is reinforcing teaching about seizure management with the family of a client who has a seizure disorder. Which of the following statements by a family member indicates an understanding of the teaching?

"I will turn him on his back during seizures.”

"I will gently restrain him during seizures.”

"I will loosen his clothing during seizures.”

"I will insert a washcloth in his mouth during seizures.”

Hint : 🧠 Support airway, prevent injury

Correct Answers:

No Correct Answers Available !

Rationale :

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35 :
A nurse is preparing to insert an indwelling urinary catheter and is verifying the client's express consent for this procedure. Which of the following actions should the nurse take?

Obtain verbal consent from the client.

Have another nurse co-sign the client's consent.

Check the medical record for the client's signature on a previous consent form.

Witness the client's signature on a consent form.

Hint : 📄 Verbal OK for routine tasks

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

36 :
A nurse is reviewing the laboratory reports of four clients. Which of the following clients should the nurse expect to have a positive fecal occult blood test?

A client who has ulcerative colitis.

A client who has cholecystitis.

A client who uses laxatives.

A client who has stomatitis.

Hint : 💩 Colon inflammation = blood risk

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

37 :
A nurse is checking for proper placement of a feeding tube. Which of the following methods is the most reliable for verification of tube placement?

Verify the bilirubin level of the tube contents.

Check the pH level of gastric contents.

Auscultate for air insufflation.

Request a chest x-ray.

Hint : 🩻 X-ray is gold standard

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

38 :
A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?

The stoma is draining a small amount of liquid stool.

The stoma protrudes slightly from the abdomen.

The stoma appears dark in color.

The stoma bleeds lightly when touched.

Hint : 🚨 Dark stoma = emergency

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

39 :
A nurse is reinforcing discharge teaching about fecal occult blood testing with a client. Which of the following instructions should the nurse include in the teaching?

Place a thick layer of stool on the specimen card.

Urinate prior to collecting the stool specimen.

Discontinue supplements containing vitamin C 24 hours before the test.

Refrain from consuming pork 7 days before the test.

Hint : 🚽 Avoid urine contamination

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

40 :
A nurse is collecting a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

Place the specimen in a clean specimen cup.

Remove 45 mL of urine from the catheter with a syringe.

Clamp the catheter tubing below the needleless port.

Clamp the catheter tubing for 60 min.

Hint : 🧫 Fresh sample = accurate test

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

41 :
A nurse is wearing sterile gloves in preparation for assisting with a client's sterile procedure. While waiting for the procedure to begin, how should the nurse position their hands?

Place one hand over the other against the part of the gown covering their upper body.

Clasp their hands together in a relaxed position behind their body at their waist.

Keep their arms at the sides of their body with their hands in a relaxed position.

Interlock their fingers and hold their hands away from their body above their waist.

Hint : 🧤 Above waist, interlocked

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

42 :
A nurse is reinforcing teaching about advance directives with a client who has terminal colorectal cancer. Which of the following statements by the client indicates an understanding of the teaching?

"I'm glad to have the opportunity to choose what kind of care I receive while I still can.”

"I can't change my mind about the care I will receive once I sign my living will.”

"Once I fill out my living will, there will be a 1-month delay before it is legally binding.”

"If I want life support, I'll need to sign a separate consent form first.”

Hint : 📘 Advance = patient decision rights

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

43 :
A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SaO2 level is 88% while on room air. Which of the following actions should the nurse take first?

Check the client's medical records to see which medications were recently administered.

Review the client's most recent SaO2 level in the medical record.

Notify the charge nurse of the client's condition.

Recheck the client's SaO2 level after having the client cough and clear their throat.

Hint : 🌬️ Recheck after airway clearance

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

44 :
A nurse is reinforcing teaching with a client who is about to start using a standard walker. Which of the following statements by the client indicates an understanding of the instructions?

"I'll keep my elbows slightly bent when I grasp the walker.”

"I'll slide the walker and move it about a foot in front of me.”

"I'll move the walker and my stronger leg ahead at the same time.”

"I'll keep the height of my walker adjusted, so I lean slightly forward.”

Hint : 🚶 Bent elbows = better balance

Correct Answers:

No Correct Answers Available !

Rationale :

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45 :
A nurse is preparing to remove an NG tube for a client who is postoperative following colon surgery. In which sequence should the nurse perform the following steps?

Apply clean gloves.
Disconnect the tube from the suction device.
Instill 50 mL of air into the tube.
Ask the client to take a deep breath.
Pinch and withdraw the tube.

Hint : 🧪 Disconnect → protect → remove

Correct Order:

No correct order available !

Rationale :

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46 :
A nurse is collecting data from a client who has diabetes mellitus. The nurse should ask which of the following to determine the client's ability to provide foot self-hygiene?

Do you have any problems taking care of your feet?

Do you go barefoot at home?

Have you noticed any problems with foot swelling?

Have you had a problem with ingrown toenails?

Hint : 👣 Assess hygiene ability first

Correct Answers:

No Correct Answers Available !

Rationale :

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47 :
A nurse is transferring a client to another unit. Which of the following statements should the nurse include in the transfer report?

He appears anxious about the transfer.

His partner has been visiting.

He is voiding adequately.

He is allergic to sulfa.

Hint : 💊 Allergy = must report

Correct Answers:

No Correct Answers Available !

Rationale :

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48 :
A nurse is caring for a client who is postoperative following a laminectomy. Which of the following actions should the nurse take when repositioning the client?

Place the client's arms above her head prior to logrolling.

Place the client in semi-Fowler's position prior to logrolling.

Place the bed in the lowest position before logrolling the client.

Place a pillow between the client's legs prior to logrolling.

Hint : 🛏️ Protect spine with pillow

Correct Answers:

No Correct Answers Available !

Rationale :

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49 :
A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Pad bony prominences before applying a restraint.

Tie the ends of the restraint to the client's bed rail.

Use a square knot to secure the client's restraint to the bed.

Observe the client's skin integrity every 2 hr.

Ensure that 2 fingers can be placed between the restraint and the client.

Hint : ⛓️ Safety, skin, circulation

Correct Answers:

No Correct Answers Available !

Rationale :

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50 :
A nurse is providing nonpharmacological interventions for a client who is experiencing pain. Which of the following actions should the nurse take?

Keep the client's room well lit.

Encourage the client to abstain from distracting activities.

Ensure that the client's room is kept at a cool temperature.

Play music in the client's room.

Hint : 🎵 Therapeutic distraction method

Correct Answers:

No Correct Answers Available !

Rationale :

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51 :
A nurse is reinforcing teaching with an older adult client about the aging process. The nurse should instruct the client that which of the following physiological changes are part of the aging process? (Select all that apply.)

Increased peripheral circulation.

Increased constipation.

Decreased muscle mass.

Decreased cough reflex.

Hint : 🧓 Age brings functional decline

Correct Answers:

No Correct Answers Available !

Rationale :

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52 :
A nurse is preparing to clean a blood spill on a bedside table. Which of the following solutions should the nurse plan to use?

Isopropyl alcohol.

Hydrogen peroxide.

Chlorhexidine gluconate.

Chlorine bleach.

Hint : 🧴 Best for blood cleanup

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

53 :
A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse take?

Use a narrower cuff to repeat the BP measurement.

Request a prescription for an antihypertensive medication.

Measure the client's BP in the other arm.

Deflate the cuff faster when repeating the BP measurement.

Hint : 🩺 Recheck before reporting

Correct Answers:

No Correct Answers Available !

Rationale :

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54 :
A nurse in a long-term care facility is caring for a client who has a gastrostomy feeding tube. Prior to administering medications, which of the following findings should the nurse report to the provider?

Hyperactive bowel sounds are present.

Stomach contents are yellowish green in color.

Aspirated stomach contents' pH measures 6.5.

Residual volume of stomach contents measures 90 mL.

Hint : 📉 pH too high for meds

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

55 :
A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?

Orthostatic hypotension.

BMI of 24.

Type 1 diabetes mellitus.

Family history of osteoporosis.

Hint : ❤️ Diabetes = heart disease risk

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

56 :
A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)

A client receives burns from a heating pad.

A client reports being dissatisfied with the temperature of the meals provided.

A client becomes disoriented and falls out of bed.

A client's visitor becomes dizzy and faints in the client's room.

A client is unable to afford the physical therapy that the provider recommends.

Hint : 📝 Report events with injury risk

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

57 :
A nurse is caring for a client who is receiving detoxification treatment for an opioid use disorder. As the nurse is preparing to administer a methadone IM injection, the client tells the nurse, "I am afraid of needles.”. Which of the following actions should the nurse take?

Remind the client that they must receive the medication as prescribed.

Tell the client not to worry because the pain will be temporary.

Request a change in the medication route to PO.

Ask one of the client's loved ones to encourage them to receive the IM medication.

Hint : 💉 Respect med route preferences

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

58 :
A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?

Stand with the crutch tips against the feet.

Bear weight on the unaffected leg.

Keep the crutches at the level of the axillae.

Hold the arms straight when walking.

Hint : 🦯 Weight goes to strong leg

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

59 :
A nurse is caring for a client who is dying. One of the client's family members tells the nurse, "I need to help. What can I do?" Which of the following actions should the nurse take?

Suggest that the family member contact a grief counselor.

Describe a personal experience with the death of a family member.

Include the family member in providing care for the client.

Ask if they have had prior experience with the death of a family member.

Hint : 💐 Let family give care

Correct Answers:

No Correct Answers Available !

Rationale :

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60 :
A nurse is planning to provide postmortem care for a client who requires an autopsy. Which of the following actions should the nurse plan to take?

Place an identification tag on the outside of the client's shroud.

Ask the assistive personnel to document the client's time of death.

Wear sterile gloves when cleaning the client's body.

Remove the client's dentures and give them to the client's family.

Hint : 🪪 ID tag stays visible

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

61 :
A nurse is assisting a client in selecting an appropriate diet. Which of the following statements should the nurse make?

Choose foods high in fiber and low in fat.

Include a variety of fruits and vegetables.

Drink plenty of water throughout the day.

Limit the intake of sugary and processed foods.

Hint : 🥗 Fiber in, fat out

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

62 :
A nurse is caring for a postoperative male client in the surgical unit. The following exhibits are available for review

The male client is 56 years old and recently underwent a laparotomy for a bowel resection due to colon cancer. He has a history of hypertension and type 2 diabetes, well-managed with medication. The surgery was uneventful, and the client was transferred to the recovery unit in stable condition. No known allergies. His pain is being managed with morphine.

0900:

Client is alert and oriented to person, place, and time. The client reports incisional pain rated 9 on a scale of 0 to 10 and is grimacing. Morphine 10 mg subcutaneously administered as prescribed.

1000:

Client is difficult to arouse. The client’s face appears flushed, and his breathing is shallow. His eyes are closed, and he is not responding to verbal stimuli. Morphine administration was noted 60 minutes ago.

• Pupils are 3 mm, equal, and reactive to light.

• Skin is warm and dry with no signs of infection at the surgical site.

• Abdomen is soft, with moderate tenderness over the surgical site.

• The client is restless and grimacing, and his respirations are shallow and slow.

• Temperature: 37.5°C (99.5°F)

• Pulse: 61/min

• Respiratory Rate: 10/min

• Blood Pressure: 99/46 mm Hg

• Pulse Oximetry: 88% on room air (normal range: 95%-100%)

• Continue with morphine as prescribed.

• Monitor vital signs every 30 minutes for the next 2 hours.

• Alert the primary healthcare provider if respiratory rate drops below 12/min or if oxygen saturation falls below 90%.

• Morphine 10 mg subcutaneously every 3 hours as needed for pain.

• The client received a dose of morphine at 0900.

Click to highlight the documentation in the client's medical record that requires further action by the nurse. To deselect documentation, click on the documentation again

Nurses' Notes • 0900: Client is alert and oriented to person, place, and time. The client reports incisional pain rated 9 on a scale of 0 to 10 and is grimacing. Morphine 10 mg subcutaneously administered as prescribed. • 1000: Client is difficult to arouse. The client’s face appears flushed, and his breathing is shallow. His eyes are closed, and he is not responding to verbal stimuli. Morphine administration was noted 60 minutes ago. Physical Examination Results • Pupils are 3 mm, equal, and reactive to light. • Skin is warm and dry with no signs of infection at the surgical site. • Abdomen is soft, with moderate tenderness over the surgical site. • The client is restless and grimacing, and his respirations are shallow and slow. Vital Signs • Temperature: 37.5°C (99.5°F) • Pulse: 61/min • Respiratory Rate: 10/min • Blood Pressure: 99/46 mm Hg • Pulse Oximetry: 88% on room air (normal range: 95%-100%)

Hint : ⚠️ Look for signs of opioid overdose.

Correct Highlights :

No correct highlights for this question!

Rationale :

Rationale to be Available Soon

63 :
A nurse is caring for a 65-year-old male client in the emergency department. The client is presenting with symptoms of a potential cardiac event and has been admitted for further evaluation.

The client is alert and oriented to person, place, and time. Lungs are clear, with no signs of distress. Deep tendon reflexes are 4+ (hyperactive) bilaterally. There is generalized weakness, but bilateral muscle strength is equal. The client also reports mild leg cramping. The heart rate is irregular and fast, with an average of 95/min. Bowel sounds are hyperactive in all four quadrants.

The client reports feeling fatigued and experiencing generalized weakness, with leg cramps. The nurse notes that the client’s skin is warm and dry, and his vital signs were recorded as described above. The client is also experiencing mild nausea and occasional dizziness, which are being monitored.

(0115)
• Heart rate: 95/min

• Tympanic temperature: 37.4°C (99.4°F)

• Blood pressure: 136/89 mm Hg

• Respiratory rate: 22/min

• Oxygen saturation: 95% on room air

(1930)

• Heart rate: 118/min

• Tympanic temperature: 36.9°C (98.4°F)

• Blood pressure: 156/94 mm Hg

• Respiratory rate: 20/min

• Oxygen saturation: 97% on room air

Complete the following sentence by selecting the most appropriate actions based on the client’s current status. The nurse should then .

Hint : 🔌 Irregular HR = urgent provider call

Rationale :

Rationale to be Available Soon

Day 1:

The client is alert but has left-sided weakness and is unable to ambulate without full assistance.

Day 2:

2+ pedal pulses present and equal bilaterally. An area of swelling and tenderness noted at the back of the right calf.

• Platelet count: 165,000/mm³ (150,000 to 400,000/mm³)

• Prealbumin level: 23 mg/dL (15 to 36 mg/dL)

Complete the following sentence by using the lists of options. The client is at risk for developing due to .

Hint : ⚠️ Calf swelling + immobility = DVT risk

Rationale :

Rationale to be Available Soon

65 :
A nurse is assisting with the care of a male client in the unit.

Nurses' Notes
Vital Signs

Day 1

The client coughs when eating. His voice is hoarse after swallowing.

Day 2

• Temperature: 38°C (100.4°F)

• Heart rate: 100/min

• Blood pressure: 118/78 mm Hg

• Respiratory rate: 18/min

• Oxygen saturation: 95% on room air

Complete the following sentence by using the list of options. The client is at risk for developing due to .

Hint : 🫁 Coughing while eating → Aspiration risk

Rationale :

Rationale to be Available Soon

66 :
A nurse is assisting in the care of a client who is postoperative following a hip arthroplasty in the orthopedic unit. The primary health care provider has prescribed pain management and positioning strategies to prevent complications.

• The client is a 72-year-old female with a medical history of hypertension, osteoarthritis, and mild cognitive impairment. No known allergies. No previous surgeries except for knee replacement 5 years ago. Currently on antihypertensive medication and occasional acetaminophen for pain.

• The client’s medical history includes a 10-year history of Parkinson's disease, diagnosed at age 62. She experiences mild tremors, occasional rigidity, and bradykinesia. Medications for Parkinson's include levodopa-carbidopa.

Day 1:

1200:

Client is resting in bed with an abductor pillow in place. Repositioned every 2 hours.

1400:

Peripheral IV in left arm infusing dextrose 5% in 0.45% sodium chloride at 125 mL/hr.

Client reports pain as 8 on a scale of 0 to 10. Oxycodone 10 mg PO administered.

Client is sleeping and is easily aroused. After 30 minutes, client reports pain as 5 on a scale of 0 to 10.

• The client is alert but slightly drowsy due to pain medication.

• Left hip surgical site clean, dry, and intact with no signs of infection.

• Moderate stiffness in the left leg but no excessive swelling.

• Diminished movement on the left side due to Parkinson's disease.

• No signs of deep vein thrombosis (DVT).

• Mild tremors noted in the hands while at rest. Provider’s Prescriptions

• Pain management: Oxycodone 10 mg PO every 4-6 hours as needed.

• Activity: Ambulation with assistance after 24 hours.

• Positioning: Abductor pillow in place to prevent hip dislocation.

• Temperature: 37.2°C (99°F)

• Pulse: 85 beats per minute

• Respirations: 18 breaths per minute

• Blood Pressure: 130/80 mmHg

• Oxygen Saturation: 98% on room air

Complete the following sentence by using the lists of options. The client is at risk for developing due to .

Hint : 🚽 Opioids → slow bowels

Rationale :

Rationale to be Available Soon

67 :
A nurse is assisting in the care of a client who has pneumonia in the medical unit.

The client is a 68-year-old male with a history of smoking for 40 years and mild chronic obstructive pulmonary disease (COPD). He presents with a new diagnosis of pneumonia, confirmed by chest x-ray and laboratory results. He reports increasing shortness of breath over the past 48 hours, along with a productive cough with greenish sputum.
He has a history of hypertension and diabetes type 2, which are both managed with medications. The client denies any recent travel or exposure to sick contacts. The primary health care provider initiated a chest x-ray and blood cultures to confirm the diagnosis of pneumonia. The client is also receiving IV antibiotics and supplemental oxygen.

Day 1,

1100:

Client admitted from the emergency department with a new diagnosis of pneumonia, confirmed by chest x-ray and laboratory results. Client reports dyspnea and exhibits shortness of breath at rest. Client is hypoxic, confirmed by oxygen saturation of 89%. Placed on oxygen at 2 L/min via nasal cannula. Congested cough with green sputum noted.

Sputum specimen obtained and sent to the laboratory for further analysis. Crackles heard on auscultation, breath sounds diminished bilaterally. IV initiated in the left forearm with a 22-gauge angiocath for intermittent antibiotic therapy and further treatment. Client remains hypoxic. Less dyspnea noted at rest, but extreme shortness of breath noted on exertion.

Day 2,

1500:

Client is stable with ongoing IV antibiotic treatment. Oxygen saturation remains at 92% on 2 L/min nasal cannula. No signs of infection at the IV site. Client's cough remains productive with green sputum. Continue monitoring respiratory status and adjust oxygen as necessary.

On physical examination, the client appears mildly distressed, with labored breathing and use of accessory muscles. The client is alert and oriented but appears fatigued. Breath sounds are diminished bilaterally with crackles noted on auscultation. There is no cyanosis, but the client is visibly short of breath, especially on exertion. The chest is clear to percussion, but there is a productive cough with green sputum. No signs of swelling or infection at the IV site. Heart sounds are regular, and there are no murmurs or additional heart sounds noted.

• Chronic Obstructive Pulmonary Disease (COPD)

• Hypertension

• Type 2 Diabetes Mellitus

• History of smoking (40 pack-years)

• Temperature: 101.2°F (38.4°C)

• Pulse: 102 beats per minute

• Respiratory Rate: 22 breaths per minute

• Blood Pressure: 130/85 mmHg

• Oxygen Saturation: 89% on room air, 92% on 2 L/min nasal cannula

• Chest x-ray: Bilateral infiltrates suggestive of pneumonia.

• Sputum culture: Positive for Streptococcus pneumoniae.

• Oxygen saturation: 89% on room air, 92% on 2 L/min oxygen via nasal cannula.

• IV antibiotics (ceftriaxone 1g daily)

• Oxygen therapy at 2 L/min via nasal cannula

• Chest x-ray and blood cultures for pneumonia confirmation

• Sputum culture for microbiological analysis

• Maintain IV access for further antibiotic therapy

Which of the following information should the nurse include in discharge teaching for the client? (Select all that apply)

Answer Options

Take antibiotics for 10 days.

Ensure the oxygen delivery system is at least 8 feet from any heat source.

Decrease the steroid dose each day.

Take antibiotic medication with or without food.

Adjust the oxygen flow rate as needed to ease breathing.

Take steroid medication in the morning.

Hint : 🫁 Prioritize oxygen and medication safety

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

Total Questions: 67

Choose Different Exam !

ATI LPN Fundamentals-2023 Exam 4

No.

1 : A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client indicates an understanding of this technique?

2 : A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations can the nurse disclose health information without the client's written consent?

3 : A home health nurse is visiting a client who has advanced Alzheimer's disease. The client's partner states, "I miss being able to go places with my friends.”. Which of the following is an appropriate response by the nurse?

4 : A nurse is recording the intake and output (I&O) for a client. The client consumed 8 oz of milk, 10 oz of water, 4 oz of gelatin, 1 egg, 1 piece of bacon, and 2 biscuits. Which volume should the nurse record on the I&O?

5 : A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification band. Which of the following actions should the nurse take to verify the client's identity?

6 : A nurse is participating in a group discussion about complicated grief associated with loss. Which of the following should the nurse identify as an example of exaggerated grief?

7 : A nurse is observing an assistive personnel (AP) apply a belt restraint to a client. Which of the following actions by the AP requires intervention by the nurse?

8 : A charge nurse is observing a newly licensed nurse who is caring for a group of clients. Which of the following statements by the newly licensed nurse indicates an understanding of infection control principles?

9 : A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps?

10 : A nurse is reinforcing teaching with a client about how to collect a stool specimen. Which of the following instructions should the nurse include?

11 : A nurse is assisting in the transfer of a client who has left-sided weakness from a bed to a chair. Which of the following actions should the nurse take?

12 : A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit. Which of the following actions should the nurse include in the plan?

13 : A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, "I'm not going to take this medication because it makes me sick and dizzy.”. Which of the following actions should the nurse take first?

14 : A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

16 : A nurse is reinforcing teaching with an older adult client who has urinary incontinence. Which of the following instructions should the nurse include?

17 : A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

18 : A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client's room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?

19 : A nurse on a medical-surgical unit receives a telephone call from an individual who identifies himself as the client's employer. The employer asks the nurse about the client's condition. Which of the following is an appropriate response by the nurse?

20 : A nurse is reinforcing teaching with a client about blood glucose monitoring. The client becomes quiet and appears distracted while the nurse is providing the instructions. Which of the following responses should the nurse make?

21 : A nurse is caring for an older adult client who has fecal incontinence. Which of the following actions should the nurse take?

22 : A home health nurse is reinforcing teaching about dietary needs with the child of a client. They state, "I don't know what to do because they're not eating.”. Which of the following responses should the nurse make?

23 : A nurse is assisting with scoliosis screenings for students at a public school. Which of the following findings should the nurse recognize as an indication of scoliosis?

24 : A nurse is setting up a sterile field in a client's room. Which of the following actions should the nurse take?

25 : A nurse is reinforcing teaching with a client who is perimenopausal. Which of the following statements by the client indicates an understanding of the teaching?

26 : A nurse is caring for a client who had an indwelling urinary catheter inserted 3 days ago. Which of the following actions should the nurse take?

27 : A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days.Which of the following laboratory findings should the nurse expect?

28 : A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

29 : A nurse is showing a newly licensed nurse how to use a mechanical lift.Which of the following statements by the newly licensed nurse indicates an understanding of this assistive device?

30 : A nurse is delegating client care to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

31 : A nurse in a long-term care facility is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

32 : A nurse is caring for an older adult client who has a hearing aid. Which of the following actions should the nurse take when the client reports hearing a whistling sound from the hearing aid?

33 : . A nurse is reinforcing teaching about end-of-life care with the partner of a client. Which of the following statements should the nurse make?

34 : A nurse is reinforcing teaching about seizure management with the family of a client who has a seizure disorder. Which of the following statements by a family member indicates an understanding of the teaching?

35 : A nurse is preparing to insert an indwelling urinary catheter and is verifying the client's express consent for this procedure. Which of the following actions should the nurse take?

36 : A nurse is reviewing the laboratory reports of four clients. Which of the following clients should the nurse expect to have a positive fecal occult blood test?

37 : A nurse is checking for proper placement of a feeding tube. Which of the following methods is the most reliable for verification of tube placement?

38 : A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?

39 : A nurse is reinforcing discharge teaching about fecal occult blood testing with a client. Which of the following instructions should the nurse include in the teaching?

40 : A nurse is collecting a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

41 : A nurse is wearing sterile gloves in preparation for assisting with a client's sterile procedure. While waiting for the procedure to begin, how should the nurse position their hands?

42 : A nurse is reinforcing teaching about advance directives with a client who has terminal colorectal cancer. Which of the following statements by the client indicates an understanding of the teaching?

43 : A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SaO2 level is 88% while on room air. Which of the following actions should the nurse take first?

44 : A nurse is reinforcing teaching with a client who is about to start using a standard walker. Which of the following statements by the client indicates an understanding of the instructions?

45 : A nurse is preparing to remove an NG tube for a client who is postoperative following colon surgery. In which sequence should the nurse perform the following steps?

46 : A nurse is collecting data from a client who has diabetes mellitus. The nurse should ask which of the following to determine the client's ability to provide foot self-hygiene?

47 : A nurse is transferring a client to another unit. Which of the following statements should the nurse include in the transfer report?

48 : A nurse is caring for a client who is postoperative following a laminectomy. Which of the following actions should the nurse take when repositioning the client?

49 : A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

50 : A nurse is providing nonpharmacological interventions for a client who is experiencing pain. Which of the following actions should the nurse take?

51 : A nurse is reinforcing teaching with an older adult client about the aging process. The nurse should instruct the client that which of the following physiological changes are part of the aging process? (Select all that apply.)

52 : A nurse is preparing to clean a blood spill on a bedside table. Which of the following solutions should the nurse plan to use?

53 : A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse take?

54 : A nurse in a long-term care facility is caring for a client who has a gastrostomy feeding tube. Prior to administering medications, which of the following findings should the nurse report to the provider?

55 : A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?

56 : A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)

57 : A nurse is caring for a client who is receiving detoxification treatment for an opioid use disorder. As the nurse is preparing to administer a methadone IM injection, the client tells the nurse, "I am afraid of needles.”. Which of the following actions should the nurse take?

58 : A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?

59 : A nurse is caring for a client who is dying. One of the client's family members tells the nurse, "I need to help. What can I do?" Which of the following actions should the nurse take?

60 : A nurse is planning to provide postmortem care for a client who requires an autopsy. Which of the following actions should the nurse plan to take?

61 : A nurse is assisting a client in selecting an appropriate diet. Which of the following statements should the nurse make?

62 : A nurse is caring for a postoperative male client in the surgical unit. The following exhibits are available for review

Correct Highlights :

63 : A nurse is caring for a 65-year-old male client in the emergency department. The client is presenting with symptoms of a potential cardiac event and has been admitted for further evaluation.

64 : Patient's data.

65 : A nurse is assisting with the care of a male client in the unit.

66 : A nurse is assisting in the care of a client who is postoperative following a hip arthroplasty in the orthopedic unit. The primary health care provider has prescribed pain management and positioning strategies to prevent complications.

67 : A nurse is assisting in the care of a client who has pneumonia in the medical unit.

Answer Options

1 :
A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client indicates an understanding of this technique?

2 :
A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations can the nurse disclose health information without the client's written consent?

3 :
A home health nurse is visiting a client who has advanced Alzheimer's disease. The client's partner states, "I miss being able to go places with my friends.”. Which of the following is an appropriate response by the nurse?

4 :
A nurse is recording the intake and output (I&O) for a client. The client consumed 8 oz of milk, 10 oz of water, 4 oz of gelatin, 1 egg, 1 piece of bacon, and 2 biscuits. Which volume should the nurse record on the I&O?

5 :
A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification band. Which of the following actions should the nurse take to verify the client's identity?

6 :
A nurse is participating in a group discussion about complicated grief associated with loss. Which of the following should the nurse identify as an example of exaggerated grief?

7 :
A nurse is observing an assistive personnel (AP) apply a belt restraint to a client. Which of the following actions by the AP requires intervention by the nurse?

8 :
A charge nurse is observing a newly licensed nurse who is caring for a group of clients. Which of the following statements by the newly licensed nurse indicates an understanding of infection control principles?

9 :
A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps?

10 :
A nurse is reinforcing teaching with a client about how to collect a stool specimen. Which of the following instructions should the nurse include?

11 :
A nurse is assisting in the transfer of a client who has left-sided weakness from a bed to a chair. Which of the following actions should the nurse take?

12 :
A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit. Which of the following actions should the nurse include in the plan?

13 :
A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, "I'm not going to take this medication because it makes me sick and dizzy.”. Which of the following actions should the nurse take first?

14 :
A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

16 :
A nurse is reinforcing teaching with an older adult client who has urinary incontinence. Which of the following instructions should the nurse include?

17 :
A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

18 :
A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client's room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?

19 :
A nurse on a medical-surgical unit receives a telephone call from an individual who identifies himself as the client's employer. The employer asks the nurse about the client's condition. Which of the following is an appropriate response by the nurse?

20 :
A nurse is reinforcing teaching with a client about blood glucose monitoring. The client becomes quiet and appears distracted while the nurse is providing the instructions. Which of the following responses should the nurse make?

21 :
A nurse is caring for an older adult client who has fecal incontinence. Which of the following actions should the nurse take?

22 :
A home health nurse is reinforcing teaching about dietary needs with the child of a client. They state, "I don't know what to do because they're not eating.”. Which of the following responses should the nurse make?

23 :
A nurse is assisting with scoliosis screenings for students at a public school. Which of the following findings should the nurse recognize as an indication of scoliosis?

24 :
A nurse is setting up a sterile field in a client's room. Which of the following actions should the nurse take?

25 :
A nurse is reinforcing teaching with a client who is perimenopausal. Which of the following statements by the client indicates an understanding of the teaching?

26 :
A nurse is caring for a client who had an indwelling urinary catheter inserted 3 days ago. Which of the following actions should the nurse take?

27 :
A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days.Which of the following laboratory findings should the nurse expect?

28 :
A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

29 :
A nurse is showing a newly licensed nurse how to use a mechanical lift.Which of the following statements by the newly licensed nurse indicates an understanding of this assistive device?

30 :
A nurse is delegating client care to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

31 :
A nurse in a long-term care facility is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

32 :
A nurse is caring for an older adult client who has a hearing aid. Which of the following actions should the nurse take when the client reports hearing a whistling sound from the hearing aid?

33 :
. A nurse is reinforcing teaching about end-of-life care with the partner of a client. Which of the following statements should the nurse make?

34 :
A nurse is reinforcing teaching about seizure management with the family of a client who has a seizure disorder. Which of the following statements by a family member indicates an understanding of the teaching?

35 :
A nurse is preparing to insert an indwelling urinary catheter and is verifying the client's express consent for this procedure. Which of the following actions should the nurse take?

36 :
A nurse is reviewing the laboratory reports of four clients. Which of the following clients should the nurse expect to have a positive fecal occult blood test?

37 :
A nurse is checking for proper placement of a feeding tube. Which of the following methods is the most reliable for verification of tube placement?

38 :
A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?

39 :
A nurse is reinforcing discharge teaching about fecal occult blood testing with a client. Which of the following instructions should the nurse include in the teaching?

40 :
A nurse is collecting a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

41 :
A nurse is wearing sterile gloves in preparation for assisting with a client's sterile procedure. While waiting for the procedure to begin, how should the nurse position their hands?

42 :
A nurse is reinforcing teaching about advance directives with a client who has terminal colorectal cancer. Which of the following statements by the client indicates an understanding of the teaching?

43 :
A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SaO2 level is 88% while on room air. Which of the following actions should the nurse take first?

44 :
A nurse is reinforcing teaching with a client who is about to start using a standard walker. Which of the following statements by the client indicates an understanding of the instructions?

45 :
A nurse is preparing to remove an NG tube for a client who is postoperative following colon surgery. In which sequence should the nurse perform the following steps?

46 :
A nurse is collecting data from a client who has diabetes mellitus. The nurse should ask which of the following to determine the client's ability to provide foot self-hygiene?

47 :
A nurse is transferring a client to another unit. Which of the following statements should the nurse include in the transfer report?

48 :
A nurse is caring for a client who is postoperative following a laminectomy. Which of the following actions should the nurse take when repositioning the client?

49 :
A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

50 :
A nurse is providing nonpharmacological interventions for a client who is experiencing pain. Which of the following actions should the nurse take?

51 :
A nurse is reinforcing teaching with an older adult client about the aging process. The nurse should instruct the client that which of the following physiological changes are part of the aging process? (Select all that apply.)

52 :
A nurse is preparing to clean a blood spill on a bedside table. Which of the following solutions should the nurse plan to use?

53 :
A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse take?

54 :
A nurse in a long-term care facility is caring for a client who has a gastrostomy feeding tube. Prior to administering medications, which of the following findings should the nurse report to the provider?

55 :
A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?

56 :
A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)

57 :
A nurse is caring for a client who is receiving detoxification treatment for an opioid use disorder. As the nurse is preparing to administer a methadone IM injection, the client tells the nurse, "I am afraid of needles.”. Which of the following actions should the nurse take?

58 :
A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?

59 :
A nurse is caring for a client who is dying. One of the client's family members tells the nurse, "I need to help. What can I do?" Which of the following actions should the nurse take?

60 :
A nurse is planning to provide postmortem care for a client who requires an autopsy. Which of the following actions should the nurse plan to take?

61 :
A nurse is assisting a client in selecting an appropriate diet. Which of the following statements should the nurse make?

62 :
A nurse is caring for a postoperative male client in the surgical unit. The following exhibits are available for review

63 :
A nurse is caring for a 65-year-old male client in the emergency department. The client is presenting with symptoms of a potential cardiac event and has been admitted for further evaluation.

64 :
Patient's data.

65 :
A nurse is assisting with the care of a male client in the unit.

66 :
A nurse is assisting in the care of a client who is postoperative following a hip arthroplasty in the orthopedic unit. The primary health care provider has prescribed pain management and positioning strategies to prevent complications.

67 :
A nurse is assisting in the care of a client who has pneumonia in the medical unit.