ATI PN EXIT EXAM PROCTORED 2022

ATI PN EXIT EXAM PROCTORED 2022 ATI PN EXIT EXAM PROCTORED ATI PN EXIT EXAM PROCTORED 1. A nurse in a long-term care facility is assisting with an inservice for newly hired assistive personnel about legal issues within the facility. Which ofIthe following should the nurse include as an example ofIassault? ANS: Informing a client the nurse is going to administer an injection even thoug h the client refuses . 2. A nurse is collecting data from who is severe pain. Which ofIthe following questions s hould the nurse ask first? ANS: "Where is your pain located?" 3. A nurse is reviewing the laboratory results for a client who is at 29 weeks gestation. F or which of the following results should the nurse notify the provider? ANS: Platelet count 95,000 mm3 4. A nurse is performing a dressing change for a client who had abdominal surgery 5 day s ago. The nurse notes organs protruding from the incision. Which ofIthe following act ions should the nurse take? ANS: Cover the exposed area with sterile, saline-soaked dressings. 5. A nurse is speaking with the adult daughter ofIa client who has Alzheimer's disease. T he daughter states, "I love my dad, but caring for him is wearing me out." Which ofIth e following response should the nurse make? ANS: "Let's discuss how caring for your father is afollowingecting your health. 6. A nurse is contributing to the plan ofIcare for a care for a client who has chest tube co nnected to a closed drainage system. Which ofIthe following actions should the nurse i nclude in the plan of care? ANS: Maintain the drainage system below the level ofIthe client's chest. 7. A nurse in an acute mental health facility is caring for a client who has borderline pers onality disorder and reports. "I am going to kill my girlfriend when I get out ofIhere." Which ofIthe following actions should the nurse take? ANS: Notify the client's care team of the threats against the partner 8. A nurse is admitting a client who is at high risk for suicide. Which ofIthe following ac tions is the nurse's priority? ANS: Search the client's personal belongings 9. A nurse is caring for a client who is 1 day postoperative and is unable to ambulate. W hich ofIthe following actions should the nurse take to promote the client's venous retur n? ANS: Maintain the sequential compression device. 10. A nurse on an acute care unity is collecting data from a schoolage Child who has cystic fibrosis. Which ofIthe following findings is the priority for th e nurse? ANS: Reports lack ofIappetite 11. a nurse working in a provider's ofollowingice receives a phone call from the parent ofI a schoolage child who has varicella. The parent asked the nurse when the child can return to sc hool. Which ofIthe following responses should the nurse make? ANS: "When the lesions have scabbed over." 12. A nurse in a pediatric clinic is collecting the data from a schoolage child whose injuries are inconsistent with the parent's stated cause. Which ofIthe f ollowing actions should the nurse take? ANS: Report the suspected abuse to a appropriate agency. 13. A nurse is collecting data from a middle adult female client who is taking melatonin. Which ofIthe following responses to the med should the nurse expect? ANS: Improved sleep 14. A nurse on a pediatric unit is collecting data from four newly admitted clients. Which ofIthe following clients should the nurse identify as being at risk for urinary retention? ANS: A schoolage child who has allergic rhinitis and is taking diphenhydramine. 15. A nurse is preparing to administer purified protein derivative (PPD) to a client who ha s suspected TB. Which ofIthe following actions should the nurse plan to take? ANS: Ensure the injection produces a wheal on the skin 16. A client who is diagnosed with Parkinson's disease verbalizes frustration due to increas e difollowingiculty with ambulation. Which ofIthe following responses should the nurs e take? ANS: Perform active ROM with your arms and legs two times a day. 17. a Nurse is collecting data from a client who has multiple fractures following a motorvehicle crash. For which of the following client statements ANS: "I am so frustrated. I cannot even open my milk carton for breakfast." 18. A nurse is caring for a client who is 4 hr postoperative following a total thyroidectomy . Which ofIthe following manifestations should the nurse report to the provider as indi cating possible hypocalcemia? ANS: Tingling ofIfingers 19. A nurse is caring for a client who has a Penrose drain. To ensure proper placement an d functioning ofIthe drain, which ofIthe following should the nurse expect to observe? ANS: The safety pin is present at the distal end of the drain. 20. A community health nurse is helping to reinforce teaching about hepatitis A with a gro up ofIemployees at a childcare facility. Which ofIthe following characteristics should t he nurse identify as an external factor that can impede learning for the participants? ANS: Poor lighting in the learning setting 21. A nurse is observing newly licensed nurse who is providing tracheostomy care for a cli ent. The nurse identifies proper performance ofIthe procedure when the newly licensed nurse selects which ofIthe following solutions to clean the inner cannula? ANS: Hydrogen peroxide 22. A nurse is caring for a client who has right sided heart failure. The client's partner exp resses concern the the client will die. Which of the following responses should the nur se make? ANS: "It is difollowingicult to see someone so sick. What have you been told ab out your partner's prognosis?" 23. A nurse is reinforcing discharge instructions with the parent ofIan infant who has rotav irus. which ofIthe following statements by the parent indicates an understanding ofIthe teaching? ANS: "I will apply diaper cream to my baby's skin during each diaper change." 24. A nurse is caring for a client who is scheduled for surgery in the morning. The nurse l earns that the client has decided not to have surgery even though he has already signed the informed consent form. Which ofIthe following actions should the nurse take? ANS: Report the situation to the provider who obtained the informed consent. 25. A nurse has to administer medications to a group ofIclients. For which ofIthe followin g client situations should the nurse complete and incident report? ANS: The nurse administered insulin lispro to a client who has diabetes mellitus and is NPO. 26. a nurse is collecting data from a client who is experiencing a situational crisis followin g the loss of a job. The client states, I don't think I can go through this again. Which o fIthe following actions is the nurse's priority? ANS: Determine ifIthe client is experiencing psychotic thinking. 27. A nurse is reinforcing discharge teaching with a client who is 48 hr post op from a ma stectomy. Which ofIthe following statements by the client indicates an understanding o fIthe teaching? ANS: "I will wear rubber gloves whenever I wash dishes or do yard work." 28. a Nurse is reinforcing teaching about home care for conjunctivitis with the parent ofIa school age child. which of the following information should the nurse include? ANS: Separate the child's used washcloth from those ofIothers. 29. a Nurse prescribes levothyroxine 0.3 PO daily for a client. Available is levothyroxine 1 50mcg/tablet. How many tablets should the nurse administer? ANS: 2 30. a nurse is collecting data from an older adult client during a routine physical exam. W hich ofIthe following client statements should the nurse identify as a possible indicatio n ofIabuse? ANS: "My son took my wallet so he can keep track ofIwhat I'm spending." 31. A nurse is assisting with a presentation at a community center about personal disaster preparedness. which ofIthe following strategies should the nurse recommend for prepar ing a home disaster supply kit? ANS: Have a supply of prescribed medications. 32. A nurse is reinforcing teaching on food selection with a client who has a moderate bur n injury. Which ofIthe following foods should the nurse recommend as being high in Vitamin C. ANS: Tomatoes 33. A nurse on a medical surgical unit is delegating tasks to an assistant. Which ofIthe foll owing tasks should the nurse delegate to the Assistant? ANS: Obtaining a client's vital signs prior to discharge 34. A Nurse is caring for a client in Buck's Traction. Which ofIthe following actions shoul d the nurse take? ANS: Allow the weights to hang freely. 35. A nurse in a long term care facility is contributing to the plan ofIcare for a client who has a new ostomy. Which ofIthe following actions should the nurse plan include? ANS: Change the appliance two times each week. 36. A nurse is receiving report on 4 clients Which ofIthe following clients should the nurs e plan to see first. ANS: A client who has pneumonia and a new onset ofIconfusion 37. A nurse is reinforcing discharge teaching with a client who has a t Tube in place follo wing a cholecystectomy. Which ofIthe following instructions should the nurse include i n the teaching? ANS: Empty the drainage bag each day at the same time. 38. A nurse is assisting with monitoring a client who is in labor and has spontaneous ruptu re ofImembranes following a vaginal examination. The provider reports the client's cer vix is dilated to 1 cm with an unengaged presenting part. Which ofIthe following actio ns should the nurse take? ANS: Apply the external fetal heart rate monitor. 39. A Nurse is collecting data from a client who has bipolar disorder and is experiencing a cute mania. Which of the following findings is the nurse's priority? ANS: lack ofIsleep 40. A nurse is reinforcing teaching with a client who has a type 2 diabetes mellitus and re ports waking during the night with tremors and anxiety. which ofIthe following inform ation should the nurse provide to help the client manage his symptoms? ANS: Eat a bedtime snack 41. a Nurse is reinforcing teaching for a client who has a coronary artery disease and is ta king lowdose aspirin daily. The nurse should include that this medication has which of the follo wing therapeutic efollowingects for CAD? ANS: Antiplatelet 42. A nurse is collecting data from a client who has an unprepared femur fracture and rate s his pain as 8 on a scale ofI0 to 10. The client is talking and caught with a visitor. W hich ofIthe following ofIthe prescribed medication should the nurse administer? ANS: Hydromorphone 5 mg orally. 43. A nurse is reinforcing preoperative teaching with a client scheduled for a bowel retenti on with ileostomy. which ofIthe following descriptions should the nurse give of the ex pected output from a mature ileostomy? ANS: liquid with little odor 44. A nurse is caring for a client who is 16 hr postoperative following a total hip arthropla sty. the client reports numbness, pain, and tingling in the afollowingected leg. Which o fIthe following actions should the nurse take first? ANS: compare capillary refill in toes bilateraly 45. A nurse is reinforcing teaching with a client who has acute diverticulitis. Which ofIthe following statements by the client indicates an understanding ofIthe teaching about the acute phase ofIdiverticulitis? ANS: "I will receive the nutrient I need through my IV Fluid" 46. A nurse in reinforcing teaching with a client about cancer prevention. The nurse shoul d include that frequent consumption ofIwhich ofIthe following foods increases the risk ofIcancer? ANS: Lamb 47. A nurse is assisting in teaching a group ofIstafollowing nurses about hepatitis A. Whic h ofIthe following modes should the nurse include as a method ofItransmitting hepatiti s A? ANS: Consumption ofIcontaminated food. 48. A nurse is reinforcing teaching with a client who is bottle feeding he fullterm newborn with formula. Which ofIthe following instructions should the nurse inclu de in the teaching? ANS: Although is is unnecessary to be rigid about feeding times, six to eight fee dings every 24 hrs should support a fullterm newborn's nutrition adequately. Fewer feedings in the initial weeks could d elay the establishment of an adequate weight-gain pattern. 49. A nurse is assisting with the plan ofIcare for a client following a transurethral resectio n of the prostate. Which of the following interventions should the nurse include in the plan ofIcare? ANS: The nurse should irrigate the bladder using strict sterile technique and m aintain closed catheter drainage system to minimize the risk of infection. 50. A nurse is reviewing a client's electronic medical record and finds that an assistive per sonnel recorder the client's temperature as 35.3 degrees Celsius (95.5 degrees F) 2 hrs earlier. Which ofIthe following actions should the nurse take firsT? ANS: Check the client's temperature. 51. A nurse is receiving change-ofshift report for four clients. Which ofIthe following clients should the nurse see first? ANS: A client whose urinary output was 100mL for the past 12 hrs 52. A nurse in reinforcing teaching about weight loss with a female older adult client who is overweight. Which ofIthe following statements should the nurse include in teaching? ANS: keep fat intake to no more that 30% of daily caloric intake. 53. A nurse is collecting data from a client who has iron deficiency anemia. Which ofIthe following findings should the nurse expect? ANS: Difollowingiculty concentrating. 54. A Nurse is collecting data from an older adult client who is 48 hr postoperative follow ing abdominal surgery. The provider writes a prescription to advance the client to a re gular Diet. For which ofIthe following findings should the nurse notify the provider? ANS: The client has absent bowel sounds. 55. A nurse is reinforcing discharge teaching with a client who is postoperative following t ransurethral resection ofIthe prostate. Which ofIthe following instructions should the n urse include in the teaching? ANS: perform Kegel exercises daily. 56. A nurse is reinforcing teaching about ways to reduce solid fat consumption with a clie nt who has an elevate cholesterol level. which ofIthe following strategies should the nu rse include in the teaching? ANS: purchase beef that is a loin cut. 57. A nurse is reinforcing teaching with a client who has a new prescription for prednisone for the treatment ofIAddison's disease. which of the following instructions should the nurse include in the teaching? ANS: You will need to schedule a bone density test. 58. A nurse is collecting data from a client who has type 2 diabetes mellitus and is concer ned about weight gain during pregnancy. Which ofIthe following responses should the nurse make? ANS: You weight gain should be the same as for someone without diabetes. 59. A nurse is reinforcing teaching with the parent ofIa preschooler who has lactose intoler ance. Which ofIthe following statements by the parent indicates an understanding ofIth e teaching? ANS: I should ofollowinger my child yogurt that has a probiotic as a snack. 60. A parent brings her adolescent son to an urgent care center and states. "He is high on s omething and needs help" The client is exhibiting agitation and paranoia and reports vi sual hallucinations. The nurse should suspect intoxication with which ofIthe following substances? ANS: Methamphetamines 61. A nurse notices an assistive personnel taking a nap in the break room during he meal t ime. The AP appears drowsy while performing routine tasks. Which of the following a ctions should the nurse take? ANS: Report the observations about the ap to the unit's nurse manager. 62. A nurse is reinforcing teaching with a client who has a fluid volume deficit about selec ting foods that have a high water content. The nurse should include that which ofIthe f ollowing raw foods contains the highest amount of waterIper 1 cup serving? ANS: Cherry tomatoes 63. The nurse is position a client who is scheduled for a lumbar puncture. The nurse shoul d assist the client into which of the following positions? ANS: Lateral Recumbent. 64. A nurse is talking with a client whose son died in a motorvehicle crash 2 weeks ago. The client states "I really thought I;d be back to my usual r outines by now, but I can't think ofIanything else except my son is gone" Which ofIthe following responses should the nurse make? ANS: Grieving for your son is hard work. It will take as much time as you need to come to terms with your loss. 65. A nurse is instructing an assistive personnel on the use of proper body mechanics whe n moving a client. which ofIthe following statements by the assistive personnel should the nurse identify as an understanding ofIthe teaching? ANS: I will use a pull sheet to help slide the client toward me. 66. a Nurse in maintaining droplet precautions for a client who has meningitis. Which ofIt he following actions should the nurse take? ANS: Wear a surgical mask within 3 feet of the client. 67. A nurse is collecting data from a female client who has a new diagnosis ofIgenital her pes. Which ofIthe following findings should the nurse expect? ANS: Painful erythematous vesicles. 68. a school nurse is having a conversation with the parents ofIan adolescent. The nurse sh ould identify which ofIthe following situations as an ethical dilemma for the parents? ANS: "We can't decide whether to try to homeschool our child or move her to a private school." 69. A nurse is preparing to administer prednisone 1mg/kg PO to a preschooler who weight s 20kg (44lb). Available is prednisone oral solution 5mg/1mL. How many mL should t he nurse administer? ANS: Round 4 mL 70. A nurse is preparing to administer a rectal suppository to a schoolage child. Which ofIthe following action should the nurse plan to take? ANS: Use one finger to insert the suppository past the anal sphincters. 71. A nurse is assisting with monitoring a client who is at 40 weeks ofIgestation and is in active labor. The nurse recognizes late deceleration on the fetal monitor tracing. Which ofIthe following actions should the nurse take? ANS: Place the client in the lateral position. 72. A nurse manager is providing an inservice on hand hygiene to assistive personnel. which ofIthe following information sho uld the nurse manager include in the in-service? ANS: Remove reigns when washing hand with soap and water. 73. A nurse is reinforcing home safety instructions with the parent ofIa newborn. Which of the following statements should the nurse include in the instructions? ANS: Place your baby's crib away from heat vents. 74. A nurse is preparing to administer a client's morning medications. Which ofIthe follow ing actions should the nurse take to verify the client's identity? ANS: Scan the facility identification board. 75. A nurse is caring for a client following a bronchoscopy procedure. Which ofIthe follo wing actions should the nurse perform first? ANS: Check for a gag reflex. 76. While administering a medication to a client, a nurse notices a frayed electrical cord c onnecting the client's continuous passive motion machine to the electrical outlet. Whic h ofIthe following actions should the nurse take? ANS: Remove the device from the client's room. 77. A nurse is caring for a client who requests information bout advance directives. Which ofIthe following responses should the nurse make? ANS: "Advance directives are written instructions regarding end-of-life care." 78. A nurse is contributing to the plan of care for a client who is at risk ofIdeveloping pre ssure ulcers. Which of the following actions should the nurse include in the plan ofIcar e? ANS: Place the client in a 30° lateral position. 79. A nurse is assisting with performing a non stress test for a client who is at 39 weeks o fIgestation which ofIthe following instructions should the nurse reinforce with the clien t? ANS: "You should depress the button on the handheld marker when you feel yo ur baby move." 80. A nurse is reinforcing discharge teaching with a client following cataract surgery. Whi ch ofIthe following instructions should the nurse include in the teaching? ANS: Sleep on the nonoperative side for 2 weeks. 81. A nurse manager is preparing to complete a performance analysis for a group ofIassisti ve personnel. The manager asks a stafollowing nurse for feedback on each assistants a bilities. Which ofIthe following actions should the stafollowing nurse take? ANS: Discuss how each AP's actions measure against the job description. 82. A nurse is preparing to administer a medication to a client when the client states " I'm sick ofIall there medication. I'm not taking any more today!" Which ofIthe following a ctions should the nurse take? ANS: Inform the client of the possible consequences of the medication refusal. 83. a nurse is contributing to the plan ofIcare for a client who is on suicide precautions. W hich ofIthe following interventions should the recommend? ANS: Encourage the client to sign a no-harm contract. 84. A nurse is reinforcing reaching for a preoperative client on how to use an incentive spi rometer. Which ofIthe following actions by the client indicates an understanding ofIthe teaching? ANS: The client attempts to elevate the cylinder by inhaling deeply. 85. A nurse at a long term care facility is part ofIa team preparing a report on the quality ofIcare at the facility. Which ofIthe following information should the nurse recommend including in the report to demonstrate improvement in care quality? ANS: The facility had 12% fewer urinary tract infections over the past 6 month s. 86. A nurse is reviewing laboratory reports for a client who has an Escherichia Coli infecti on and is receiving gentamicin. Which ofIthe following results should the nurse report to the provider before administering the next dose? ANS: Creatinine 2.5 mg/dL 87. A nurse working in a community clinic is caring for an adolescent who has infectious mononucleosis. The client asks the nurse to explain how the disease was acquired. The nurse should explain that an individual acquires this disease by which ofIthe following . ANS: Sharing eating utensils with an infected person 88. A nurse is reinforcing teaching with a client who has hypothyroidism and a prescriptio n for levothyroxine. Which ofIthe following instructions should the nurse include in th e teaching? ANS: "You will need to take the medication for the rest of your life." 89. A nurse is collecting data from a postpartum client who had a vaginal birth 2 days ago . Which ofIthe following findings is the nurse's priority to report to the provider? ANS: Client reports during with urination. 90. A nurse is reinforcing reaching with a client about a planned thoracentesis. Which ofIt he following information should the nurse include in the teaching? ANS: You will need to be monitored for 1 hour after the procedure." 91. A nurse is contributing to the plan ofIcare for an older adult client who has difollowin giculty sleeping. Which ofIthe following interventions should the nurse include in the plan? ANS: Establish a regular exercise routine 2 hr or more before bedtime. 92. A nurse in a provider's ofollowingice is reinforcing teaching with a client who has a ne w prescription for ferrous sulfate elixir. Which of the following statements by the clien t should indicate to the nurse an understanding ofIthe teaching? ANS: I will rinse my mouth after taking this medication. 93. A licensed practical nurse on a medical surgical unit is working with an RN and an As sistive personnel. Which ofIthe following assignments should the LPN expect to receiv e? ANS: Administering an NG tube feeding to a client who had a stroke 94. A nurse is caring for a client who has schizophrenia and is experiencing auditory hallu cinations. Which ofIthe following actions should the nurse take? ANS: Ofollowinger the client headphones to listen to music. 95. A nurse is reinforcing teaching with a client about taking warfarin to treat atrial fibrilla tion. Which ofIthe following statements by the client indicates an understanding ofIthe teaching? ANS: If I forget to take a dose, I can take it later on the same day." 96. A nurse is working with an interpreter to explain a diagnostic procedure to a client wh o doesn't speak the same language as the nurse. Which ofIthe following actions should the nurse take? ANS: Ensure the interpreter is culturally compatible with the client. 97. A nurse is reinforcing discharge teaching with a client who has dependent personality disorder. Which ofIthe following instructions should the nurse include in the discharge teaching? ANS: Demonstrate assertiveness. 98. A nurse is contributing to the discharge plan for a client who had a knee arthroplasty. Which ofIthe following actions should the nurse identify as the priority? ANS: Check the client's mobility 99. A nurse in a longterm care facility is assisting with the admission ofIa client who requires oropharyngea l suctioning. Which ofIthe following supplies does the nurse need to perform this task? ANS: Yankauer catheter 100. A nurse is collecting data from a client who is 24 hr post op from an open colo n resection, has a clamped NG tube, and is resuming a clean liquid diet. Which ofIthe following findings should the nurse report to the provider? ANS: Client reports vomiting green-tinged fluid. 101. A nurse is caring for a client who took an overdose ofIacetaminophen. Which o fIthe following medications should the nurse plan to administer to the client? ANS: Acetylcysteine 102. A nurse delegates the collection ofIa sputum specimen from a client who has tu berculosis to an assistive personnel. At which of the following times should the nurse i nstruct the ap to collect the specimen? ANS: As soon as the client wakes up. 103. A nurse in a long term care facility is using validation therapy with a client wh o has dementia. The client becomes agitated and asks why his wife who died several y ears ago has not visited him. Which ofIthe following responses should the nurse make? ANS: You must miss your wife. Let's take a walk and you can tell me about he r. 104. A nurse is reinforcing teaching with a client who has a prescription for nitrogly cerin sublingual tablets Which ofIthe following instructions should the nurse include in the teaching? ANS: Take up to three tablets during a single angina episode. 105. a Nurse is caring for a client who is post op following an open reduction with i nternal fixation ofIthe ankle. The client report pain and the nurse notes that the afollow ingected extremity is cool, pale, and has a weak pulse. The nurse calls the surgical assi stant who responds "it has always been like that" Which ofIthe following actions shoul d the nurse take first? ANS: Notify the nursing supervisor. 106. a nurse is collecting data from a client who has Tourette syndrome. The client r eports taking haloperidol 0.5 mL orally 3 times a day at home. Which of the following components ofIthe prescription should the nurse question? ANS: Dosage 107. A nurse is caring for a female client who has an indwelling urinary catheter. w hich ofIthe following actions should the nurse take? ANS: Wipe the drainage port with an antiseptic wipe after emptying urine from bag. 108. A nurse is reinforcing teaching with a newborn's parents about umbilical cord c ard. Which ofIthe following statements by a parent indicates an understanding ofIthe in struction? ANS: "I will give our baby sponge baths until the cord falls ofollowing." 109. A nurse who is facilitating a support group notices that one client in the group i s extremely talkative, to the point where others in the group have difollowingiculty sha ring their own ideas. Which ofIthe following strategies should the nurse use to facilitat e the group process with this client? ANS: Speak privately to the client about this behavior. 110. A nurse at a clinic is performing vision testing for a client following a head inj ury. Which ofIthe following findings should the nurse identify as a problem with pupil accommodation? ANS: Lack of change in pupil size when the client looks from a far to a near ob ject. 111. A nurse is reinforcing teaching with a client who has cancer and a new prescrip tion for fentanyl transdermal patches. Which of the following statements by the client i ndicates an understanding ofIthe teaching? ANS: "I will fold the patch with the adhesive sides inward before discarding it." 112. A nurse is contributing to the plan ofIcare for a client who had a vaginal delive ry 4 hours ago and has a 4th degree perineal laceration. Which ofIthe following action s should the nurse recommend? ANS: Instruct the client to use a sitz bath at least twice a day. 113. A nurse is collecting data from a client who sustained spinal cord injuries from fractures to the t1 and t2 vertebrae. Which ofIthe following client outcomes should the nurse expect? ANS: Flexes and extends the shoulders 114. A nurse is preparing to administer an influenza virus immunization to a client b y the intradermal route. Which ofIthe following actions should the nurse take? ANS: Avoid massaging the site after injecting the vaccine 115. A nurse assisting with a childbirth class is discussing non pharmacological strat egies used during labor. Which ofIthe following statements by a client indicates an und erstanding ofIcutaneous stimulation? ANS: "I should use counterpressure for back pain during labor." 116. A nurse is assisting with the admission ofIa client who has major depressive dis order. Which ofIthe following communication technique should the nurse use to establi sh a trusting relationship with the client? ANS: Ofollowingering general leads 117. A nurse is preparing to administer medications to a client who is NPO and is re ceiving enteral feedings through an NG tube. Which ofIthe following prescription shou ld the nurse clarify with the provider? ANS: Metoprolol ER 50mg per NG tube BID 118. A nurse is contributing to the plan ofIcare for a client who is newly diagnosed with iron deficiency anemia. Which ofIthe following foods should the nurse include in the plan as having the highest amount ofIiron? ANS: Boiled spinach 119. A nurse is administering lorazepam to a client who is scheduled for surgery wit hin 1 yr. Which of the following actions should the nurse take after administering the medication ? ANS: Instruct the client not to get out of bed. 120. A nurse is observing an AP caring for a client. For which ofIthe following acti ons should the nurse intervene? ANS: An AP reports client information to the oncoming AP in the hallway 121. A nurse is observing a stable preterm newborn who develops apnea for longer t han 20 sec, with a decrease heart rate ofI20/min. Which ofIthe following actions shoul d the nurse take first? ANS: Flick the sole ofIthe newborn's foot 122. A nurse is assisting in the plan ofIcare for a female client who is to undergo a 12- lead ECG. Which ofIth ofollowing actions should the nurse include in the plan ofIcare ? ANS: Instruct the client to remain still while the test is performed. 123. A nurse is preparing to insert an indwelling urinary catheter for a female client who has a urinary retention. Which of the following actions should the nurse take? ANS: Open the outer package flap of the catheterization kit away from her bod y. 124. A nurse I caring for a client who has expressive aphasia following a stroke. Wh ich ofIthe following communication methods should the nurse use? ANS: Provide a picture board. 125. A nurse is caring for a client who is NPO and has an NG tube attached to sucti on for gastric decompression. Which ofIthe following actions should the nurse take ifIt he client experiences abdominal distention? ANS: Irrigate the tube with normal saline. 126. A nurse is assisting with admitting a client who has colorectal cancer. When C ollecting data from the client, which ofIthe following manifestations should the nurse e xpect? ANS: Abdominal cramps 127. A nurse is preparing to administer digoxin to a client who has heart failure. Wh ich ofIthe following findings should indicate to the nurse that the medication is efollow ingective? ANS: Cardiac workload decreases 128. A nurse is discussing alopecia with a client who is scheduled to begin chemoth erapy. Which ofIthe following statements should the nurse make? ANS: "Your oncologist may prescribe a cold cap to wear during treatment to re duce hair loss." 129. A nurse is reinforcing teaching about stress management techniques with a clie nt who has moderate anxiety disorder. Which of the following responses by the client i ndicates an understanding ofIthe teaching? ANS: "I will imagine myselfIin a calm place when I can't concentrate." 130. a nurse is caring for a female client during an outpatient clinic visit. Which ofIt he following findings places the client at risk for coronary artery disease? ANS: The client's LDL level 131. A nurse is reinforcing teaching with a client who is at 20 weeks ofIgestation an d will undergo routine abdominal ultrasonography the following day. Which ofIthe foll owing statements should the nurse include in the teaching? ANS: "You will need to have a full bladder for the procedure." 132. a nurse is reviewing the plan ofIcare for a client who is 3 hr postoperative follo wing a thyroidectomy. Which ofIthe following is the priority intervention? ANS: Listen to the client for evidence ofIstridor. 133. A nurse in a long term care facility is reviewing information about health care associated infection with a newly licensed nurse. Which ofIthe following information s hould the nurse include? ANS: Prolonged use of corticosteroids is a risk factor for infection. 134. A nurse is collecting data on a client who has post traumatic stress disorder Wh ich ofIthe following manifestations should the nurse expect? ANS: Hypervigilance 135. A nurse is caring for a client who has multiple sclerosis. Which ofIthe followin g manifestations should the nurse expect? ANS: Ataxia 136. A nurse is checking a newborn's vital signs. Which ofIthe following methods of temperature measurement should the nurse use? ANS: Axillary 137. A nurse in a provider's ofollowingice is collecting data from a preschooler. Whi ch ofIthe following findings should the nurse report to the provider? ANS: Heart rate 146/min 138. A nurse is preparing to discharge a middle adult client who is immunocomprom ised. Which ofIthe following immunizations should the nurse plan to administer? ANS: Pneumococcal polysaccharide (PPSV) vaccine 139. A nurse is caring for a client who had a bone marrow transplant 3 days ago for treatment for leukemia. Which ofIthe following findings should the nurse identify as a safety hazard? ANS: A visitor brought the client a bouquet ofIflowers. 140. A nurse is caring for an infant who is receiving IV fluids for dehydration. Whic h ofIthe following should the nurse recognize as a positive response to therapy? ANS: Moist mucous membranes 141. A nurse is preparing a client for surgery. The client states, "I'm sure this surger y will not help me get better" Which ofIthe following responses should the nurse make ? ANS: "You're saying that you are doubtful that this procedure will benefit you. " 142. A nurse at a long term care facility is transcribing new prescriptions for 4 client s. Which ofIthe following prescriptions is accurately transcribed by the nurse? ANS: Potassium chloride 20 mEq PO every morning 143. A charge nurse in a long term care facility notices an assistants repeated failure to provide oral care for clients. Which of the following actions should the nurse take? ANS: Discuss the unacceptable behavior with the AP while reinforcing expectati ons. 144. A Nurse is reinforcing teaching with a male client who is uncircumcised about obtaining a cleancatch midstream urine specimen. Identify the sequence ofIactions the client should take after washing his hands. ANS: Retract the foreskin to expose the glans cleanse the penis using an antiseptic swab Begin to urinate pass the urine container into the stream collect the specimen move the container out ofIthe stream Replace the foreskin 145. A nurse is reinforcing teaching with a client who has a new diagnosis ofItype 2 diabetes mellitus and inquires about information concerning oral anti diabetic agents. I n addition to the provider, where should the nurse refer the client for information? ANS: A pharmacist Package inserts American Diabetes Association 146. A nurse is caring for four clients who are all scheduled for surgery on the same day. Which of the following nursing actions demonstrates that the nurse possesses efo llowingective time management skills? ANS: Gathers all needed supplies and equipment before entering client rooms Completes one task before beginning a new task Documents the clients' preoperative vital signs when they are taken Delegates tasks to an assistive personnel (AP) that are within his range of function 147. A nurse in a long term care facility is serving on the ethics committee, which is addressing a client care dilemma. Which ofIthe following strategies will facilitate reso lving the dilemma? ANS: Determine the facts related to the dilemma. Identify possible solutions. Consider the client's wishes.