ATI PN COMPREHENSIVE EXIT EXAM Latest Update Graded A 2023

1. A nurse is caring for a client who speaks a language different from the nurse. Which of the following actions should the nurse take? use a facility based interpreter of the same sex as the client 2. A nurse is caring for a 1 day old newborn who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take? Ensure that the newborn wears a diaper 3. A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that is safe to eat which of the following foods while taking this medication? Whole grain bread 4. A nurse in a PACU is caring for a client who is postoperative following a knee arthroplasty using general anesthesia. Which of the following findings should the nurse report to the provider immediately? Nasal flaring is present with inspiratory stridor 5. A nurse is planning care for a group of clients. Which of the following methods should the nurse use to manage time effectively? Gather supplies prior to completing a dressing change 6. a nurse is assessing a client who is receiving peritoneal dialysis for manifestation for peritonitis. Which of the following findings should the nurse identify as the first indication of peritonitis? Abdominal pain 7. A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life sustaining measures. The client’s family wants the client to have life sustaining measures. Which of the following actions should the nurse take? Arrange for an ethics committee meeting to address the family’s concerns 8. A nurse is preparing to administer a NG tube feeding to a school age child. Which of the following actions should the nurse plan to take? Measure the tubing form the nose to the distal port 9. A nurse is reviewing the lab report of a client who has been receiving lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8. which of the following orders from the provider should the nurse expect? Administer the medication 10. A nurse is a mental health facility is airing for a child who is experiencing a panic level of anxiety. Which of the following actions should the nurse take? Encourage the client to take about his feelings 11. A nurse is teaching a group of newly licensed nurses about client advocacy. Which of the following statements by a newly licensed nurse indicates an understandings of the teaching? I will interfere if there is a conflict between a client and his provider 12. A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse take? offer the client headphones to listen to music. 13. A nurse is reinforcing teaching with a client about taking warfarin to treat atrial fibrillation. Which of the following statements by the client indicates an understanding of the teaching? If I forget to take a dose, I can take it later on the same day." 14. A nurse is working with an interpreter to explain a diagnostic procedure to a client who doesn't speak the same language as the nurse. Which of the following actions should the nurse take? : Ensure the interpreter is culturally compatible with the client. 15. A nurse is reinforcing discharge teaching with a client who has dependent personality disorder. Which of the following instructions should the nurse include in the discharge teaching? Demonstrate assertiveness. 16. A nurse is contributing to the discharge plan for a client who had a knee arthroplasty. Which of the following actions should the nurse identify as the priority? Check the client's mobility 17. A nurse in a longterm care facility is assisting with the admission of a client who requires oropharyngeal suctioning. Which of the following supplies does the nurse need to perform this task? : Yankauer catheter 18. A nurse is collecting data from a client who is 24 hr post op from an open colon resection, has a clamped NG tube, and is resuming a clean liquid diet. Which of the following findings should the nurse report to the provider? Client reports vomiting green-tinged fluid. 19. A nurse is caring for a client who took an overdose of Acetaminophen. Which of the following medications should the nurse plan to administer to the client? ANS: Acetyl cysteine 20. A nurse delegates the collection of a sputum specimen from a client who has tuberculosis to an assistive personnel. At which of the following times should the nurse instruct the ap to collect the specimen? As soon as the client wakes up. 21. A nurse in a long term care facility is using validation therapy with a client who has dementia. The client becomes agitated and asks why his wife who died several years ago has not visited him. Which of the following responses should the nurse make? You must miss your wife. Let's take a walk and you can tell me about her. 22. A nurse is reinforcing teaching with a client who has a prescription for nitroglycerin sublingual tablets Which of the following instructions should the nurse include in the teaching? Take up to three tablets during a single angina episode. 23. a Nurse is caring for a client who is post op following an open reduction with internal fixation of the ankle. The client report pain and the nurse notes that the follow ingected extremity is cool, pale, and has a weak pulse. The nurse calls the surgical assistant who responds "it has always been like that" Which of the following actions should the nurse take first? Notify the nursing supervisor. 24. a nurse is collecting data from a client who has Tourette syndrome. The client reports taking haloperidol 0.5 mL orally 3 times a day at home. Which of the following components of the prescription should the nurse question? Dosage 25. A parent asks about the human papillomavirus (HPV) vaccine. Which information will the nurse include in the teaching session? b. It is recommended for females ages 11 to 26. 26. A nursing student is providing education to a group of older adults who are in an independent living retirement village. Which statement made by the nursing student requires the nurse to intervene? c. infection at this point in your life.” “Using pillows and taking pain medication if needed before having sexual intercourse often help alleviate pain and improve sexual 27. A nurse is interviewing a woman who uses a diaphragm. Which information from the patient will require the nurse to follow up? a. “I have lost 12 pounds on this diet.” 28. A nurse is conducting a sexual assessment. Which question is appropriate for the nurse to ask? a. Have you noticed any changes in the way you feel about yourself? 29. A 15-year-old patient is concerned because her mother wants her to receive the human papillomavirus (HPV) vaccination, but the patient is unsure if she wants it. Which response by the nurse is most therapeutic? a. Ask the patient what concerns she may have about the vaccination. 30. A nurse is reviewing a patient’s history. Which priority finding will alert the nurse to assess the patient for possible sexual dysfunction? b. Takes exercise classes 31. A nurse is assessing a child for sexual abuse. Which assessment findings will the nurse expect? a. Physical aggression and sleep disturbances 32. The nurse is teaching a patient how to use a condom. Which instructions will the nurse provide? d. Hold onto the condom when pulling out. 33. A nurse is caring for a patient with dyspareunia. In which order will the nurse provide care, starting with the first step? 1. Determine which signs and symptoms of dyspareunia the patient has. 2. Mutually decide upon goals and objectives for dyspareunia. 3. Ask the patient if the dyspareunia is improving. 4. Develop a nursing diagnosis for the patient. 5. Use resources to help resolve the problem. b. 1, 4, 2, 5, 3 34. A nurse manager is planning an audit to measure the quality of care on the unit. Which of the following is the most appropriate source for the nurse to consult? b. Evidence-based practice data 35. A nurse is caring for a client who had gastric bypass surgery 1 week ago and has signs of early dumping syndrome. Which of the following findings should the nurse expect? (Select all that apply) b. Syncope c. Diaphoresis d. Vertigo 36. A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect? d. heightened perceptual field 37. A nurse is delegating tasks to an assistive personnel. Which of the following instructions demonstrates appropriate communication of the task? b. "Obtain a blood pressure reading from the client in room 116 after lunch and report a systolic level less than 90." 38. A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood pressure. The nurse should recognize that these findings are potential manifestations of which of the following? b. Heroin intoxication 39. A nurse is assessing an older adult client who had a stroke. Which of the following findings should the nurse recognize as an indication of dysphagia? a. Abnormal movements of the mouth 40. *A nurse is providing preoperative teaching to a client who will use PCA morphine sulfate following surgery. Which of the following information should the nurse include? b. The client can administer a dose of medication every 6 to 8 min. 41. A nurse is assisting the provider with a paracentesis for a client who has ascites. Following collection of the specimen, which of the following actions should the nurse take next b. Measure the drainage. 42. A nurse is caring for a client in an inpatient facility who tells the nurse that she is leaving because the facility policy prohibits smoking inside. Which of the following actions should the nurse take? d. Call the provider for a discharge prescription. 43. A nurse is preparing to administer a measles, mumps, rubella (MMR) immunization to a child. Which of the following is a contraindication for administration? c. Minor acute illness 44. A nurse is preparing to administer 2.5 mL of medication intramuscularly to an adult client. Which of the following is the safest site for the nurse to use? a. Ventrogluteal 45. A nurse is teaching a female client how to reduce the risk of urinary tract infections (UTIs). Which of the following should the nurse include as a risk factor for developing a UTI? a. Wearing underwear with a cotton crotch 46. A nurse is providing discharge instructions for a client who has a new prescription for furosemide. Which of the following client statements indicates a need for further teaching? c. "I will notify the nurse if I have muscle cramps." 47. A nurse is caring for a client who has a prescription for atorvastatin. Which of the following client conditions is a contraindication to this medication? d. chrohn’s disease 48. A nurse is planning care for an adolescent who has chronic renal failure. Which of the following actions should the nurse include in the plan of care? a. Encourage a diet high in calcium. 49. A nurse is assessing a client 1 hr following birth and notes that her uterus is boggy and located 2 cm above the umbilicus. Which of the following actions should the nurse take first? d. Give oxytocin IV bolus. 50. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following interventions should the nurse perform c. Position the head of bed at 30 degrees during feeding. 51. A nurse is caring for a 7 month-old infant who is being treated for severe dehydration. Which of the following assessment findings indicates treatment has been effective? c. Cool, mottled skin 52. A nurse is providing teaching to a client who has esophageal cancer and is scheduled to start radiation therapy. Which of the following should the nurse include in the teaching? b. Apply a warm compress to the irradiated site. 53. A nurse in a provider's office is providing education to a client who is 16 weeks of gestation and has a new prescription for ferrous sulfate. Which of the following instructions should the nurse provide b. "Take your iron medication with fluids other than coffee or tea." 54. A nurse receives a change-of-shift report on four clients. Based on the shift report information, which of the following clients should the nurse plan to assess b. A client who has anorexia and peripheral edema 55. A nurse administers a dose of metoclopramide to a client prior to chemotherapy treatment. Which of the following medications should the nurse administer? a. Albuterol sulfate 56. A client who does not speak English arrives at the emergency department accompanied by a child. Which of the following actions should the nurse take? a. Ask the assistive personnel to assist the client in signing consent for treatment 57. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displays toxicity. Which of the following actions should the nurse take? c. Administer calcium gluconate IV. 58. A nurse is collecting data from a client in an outpatient clinic and observes extensive bruising on the client’s arms. This nurse suspects the client is experiencing intimate partner abuse. Which of the following is the nurse’s priority action? Offer support and create a safe, trusting environment 59 A nurse in an urgent care clinic is caring for a client who reports recently using methylenedioxy-methamphetamine. Which of the following findings should the nurse expect? Hallucinations 60. A nurse is reinforcing teaching with a client who has a prescription for ferrous sulfate elixir. Which of the following statements by the client indicates an understanding of the teaching? I will mix the medication with water 61. A nurse is collecting data from a client who received oxytocin 10 units IM 30 min ago for excessive vaginal bleeding. Which of the following findings should the nurse expect? o Boggy fundus 3 fingerbreadths above the umbilicus 62. A nurse is attending an educational workshop about client confidentiality. Which of the following actions b y the nurse indicates an understanding of the teaching? o Changes her personal login password at random intervals 63. A nurse is assisting with discharge planning for a group of clients. Which of the following clients should the nurse recommend a home health referral? o An older adult client who has heart failure and lives alone 64. A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following instructions should the nurse include in the teaching? o You might experience swollen gums while taking this medication 65. A nurse is preparing to administer paroxetine 15 mg PO oral suspension to a client who has a depressive disorder. The amount available is 10 mg/ 5 mL. How many mL should the nurse administer?(Round answer to the nearest tenth.) • 7.5 mL 66. A nurse is reinforcing teaching with a client who is at 38 weeks of gestation and is to undergo a contraction stress test. Which of the following statements by the client indicates an understanding of the teaching? o I am having this test because my baby was nonstress test reactive during a 67. A nurse is discussing health practices with the mother of a toddler who is from a different cultural background than the nurse. Which of the following statements by the mother indicates that she practices cupping? o I sometimes place a bottle containing steam against my child’s skin 68. A nurse is reinforcing teaching with a client who has primary open-angle glaucoma and has a prescription for timolol eye drops. Which of the following statements by the client indicates an understanding of the teaching? o I should check my heart rate while taking this medication 69. A nurse is collecting data from a preschooler who has severe dehydration. Which of the following findings should the nurse expect? o Weight loss of 10% 70. A nurse is contributing to the plan of care for an older adult client. Which of the following physiological changes should the nurse consider when administering medication? o Decreased kidney function 71 A nurse is caring for a client who is taking multiple medications and asks about possible interactions. To which of the following members of the interdisciplinary team should the nurse make a referral? o Advanced practice nurse 72. A nurse is collecting data from a client who just received his first dose of sulfasalazine to treat ulcerative colitis. Which of the following findings should the nurse identify as an indication of an allergic reaction to this medication? o Dyspnea 73. A nurse is collecting nutritional data from a group of adult clients. For which of the following clients should the nurse recommend an interprofessional care conference with a dietician? o A client who has a body mass index of 32 74. A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? o Soiled dressings should be placed in a biohazard trash receptacle 75. A nurse is preparing a vitamin K injection to give to a newborn. The newborn’s mother questions the purpose of this medication. Which of the following responses should the nurse make? o This medication will decrease the risk of hemorrhage in your newborn 76. A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following findings should the nurse report to the provider? o Fruity breath odor 77. A nurse is caring for a client who has a vacuum-assisted closure system to treat a pressure ulcer. Which of the following actions should the nurse take? o Use an adhesive remover to remove tape before reapplying a dressing 78. A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent? o I am thankful I am done having children 79. A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? o Measure the duration of the seizure o Lower the side rails of the bed when the seizure begins o Insert an oral airway into the clients mouth 80. A nurse is collecting data from a client who is at 12 weeks of gestation. The client states, “We've been trying to get pregnant for several months, but now I'm not so sure I'm ready.” Which of the following responses should the nurse make? o Many women experience feelings of ambivalence during pregnancy 81. A nurse is caring for four clients. Which of the following situations require a signed consent form? o Administering an iron injection Z-track method 82. A nurse is receiving a report on four clients. The nurse should plan to collect data from which of the following clients first? o A preschooler who has epiglottis and is drooling 83. A nurse is caring for a client who reports frequent headaches after taking chewable isosorbide dinitrate. Which of the following statements should the nurse include? o The headaches should decrease as you get used to the medication 84. A nurse is assisting in the plan of care for a female client who is to undergo a 12- lead ECG. Which of the following actions should the nurse include in the plan of care? ANS: Instruct the client to remain still while the test is performed. 85. 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. 86. A nurse I caring for a client who has expressive aphasia following a stroke. Which of the following communication methods should the nurse use? ANS: Provide a picture board. 87. A nurse is caring for a client who is NPO and has an NG tube attached to suction for gastric decompression. Which of the following actions should the nurse take if the client experiences abdominal distention? ANS: Irrigate the tube with normal saline. 88. A nurse is assisting with admitting a client who has colorectal cancer. When Collecting data from the client, which of the following manifestations should the nurse expect? ANS: Abdominal cramps 89. A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following findings should indicate to the nurse that the medication is effective? ANS: Cardiac workload decreases 90. A nurse is discussing alopecia with a client who is scheduled to begin chemotherapy. Which of the following statements should the nurse make? ANS: "Your oncologist may prescribe a cold cap to wear during treatment to reduce hair loss." 91. A nurse is reinforcing teaching about stress management techniques with a client who has moderate anxiety disorder. Which of the following responses by the client indicates an understanding of the teaching? ANS: "I will imagine myself in a calm place when I can't concentrate." 92. a nurse is caring for a female client during an outpatient clinic visit. Which of the following findings places the client at risk for coronary artery disease? ANS: The client's LDL level 93. A nurse is reinforcing teaching with a client who is at 20 weeks of gestation and will undergo routine abdominal ultrasonography the following day. Which of the following statements should the nurse include in the teaching? ANS: "You will need to have a full bladder for the procedure." 94. a nurse is reviewing the plan of care for a client who is 3 hr postoperative following a thyroidectomy. Which of the following is the priority intervention? ANS: Listen to the client for evidence of stridor. 95. A nurse in a long term care facility is reviewing information about health care associated infection with a newly licensed nurse. Which of the following information should the nurse include? ANS: Prolonged use of corticosteroids is a risk factor for infection. 96. A nurse is collecting data on a client who has post-traumatic stress disorder which of the following manifestations should the nurse expect? ANS: Hyper vigilance 97. A nurse is caring for a client who has multiple sclerosis. Which of the following manifestations should the nurse expect? ANS: Ataxia 98.A nurse is checking a newborn's vital signs. Which of the following methods of temperature measurement should the nurse use? ANS: Axillary 99. A nurse in a provider's office is collecting data from a preschooler. Which of the following findings should the nurse report to the provider? ANS: Heart rate 146/min 100. A nurse is preparing to discharge a middle adult client who is immunocompromised. Which of the following immunizations should the nurse plan to administer? ANS: Pneumococcal polysaccharide (PPSV) vaccine 101.A nurse is caring for a client who had a bone marrow transplant 3 days ago for treatment for leukemia. Which of the following findings should the nurse identify as a safety hazard? ANS: A visitor brought the client a bouquet of flowers. 101. A nurse is caring for an infant who is receiving IV fluids for dehydration. Which of the following should the nurse recognize as a positive response to therapy? ANS: Moist mucous membranes 102. A nurse is preparing a client for surgery. The client states, "I'm sure this surgery will not help me get better" Which of the following responses should the nurse make? ANS: "You're saying that you are doubtful that this procedure will benefit you." 103. A nurse at a long term care facility is transcribing new prescriptions for 4 clients. Which of the following prescriptions is accurately transcribed by the nurse? ANS: Potassium chloride 20 mEq PO every morning 104. A charge nurse in a long term care facility notices an assistant’s 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 expectations. 105. A Nurse is reinforcing teaching with a male client who is uncircumcised about obtaining a cleancatch midstream urine specimen. Identify the sequence of actions 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 of the stream Replace the foreskin 106. 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. In addition to the provider, where should the nurse refer the client for information? ANS: A pharmacist Package inserts American Diabetes Association 107. 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 efollowingective 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 108. A nurse in a long term care facility is serving on the ethics committee, which is addressing a client care dilemma. Which of the following strategies will facilitate resolving the dilemma? ANS: Determine the facts related to the dilemma. Identify possible solutions. Consider the client's wishes 109. In planning care for the patient with ulcerative colitis, the nurse identifies which nursing diagnoses as a priority? C. Fluid volume deficit 110. The nurse is teaching about irritable bowel syndrome (IBS). Which of the following would be most important? A. Reinforcing the need for a balanced diet 111. The nurse is planning care for the patient with celiac disease. In teaching about the diet, the nurse should instruct the patient to avoid which of the following for breakfast? A. Cream of wheat 112. The nurse is caring for a patient with suspected diverticulitis. The nurse would be most prudent in questioning which of the following diagnostic tests ordered? B. Barium enema 113. When the nurse is gathering information for the assessment, the patient states, “My stomach hurts about 2 hours after I eat.” Based upon this information, the nurse knows the patient likely has a: B. Duodenal ulcer 114. The registered nurse is conducting an in-service for colleagues about peptic ulcers. The nurse would be correct in identifying which of the following as a causative factor? C. H. pylori 115. The nurse is caring for the patient’s post-surgical removal of a 6mm oral cancerous lesion. The priority nursing measure would be to: A. Maintain a patent airway 116. The nurse is assisting in the care of a patient with diverticulosis. Which of the following assessment findings would necessitate a report to the doctor? D. Hemoglobin 26% and hematocrit 32 117. The nurse is assessing the client admitted for possible oral cancer. The nurse identifies which of the following as a late-occurring symptom of oral cancer? C. Pain 118. An obstetrical client decides to have an epidural anesthetic to relieve pain during labor. Following administration of the anesthesia, the nurse should: C. Monitor the client for respiratory depression 119. The nurse is performing an assessment of an elderly client with a total hip repair. Based on this assessment, the nurse decides to medicate the client with an analgesic. Which finding most likely prompted the nurse to decide to administer the analgesic? D. The client grimaces during care. 120. A client who has chosen to breastfeed complains to the nurse that her nipples became very sore while she was breastfeeding her older child. Which measure will help her to avoid soreness of the nipples? B. Breaking suction by placing a finger between the baby’s mouth and the breast when she terminates the feeding 121. The nurse asked the client if he has an advance directive. The reason for asking the client this question is: B. Much confusion can occur with the client’s family if he does not have an advanced directive. 122. The doctor has ordered a Transcutaneous Electrical Nerve Stimulation (TENS) unit for the client with chronic back pain. The nurse teaching the client with a TENS unit should tell the client: B. “Please report skin irritation to the doctor.” 123. The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. Which action should receive priority? B. Applying oxygen 124. The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instruction should be given to the client? B. Avoid rapid movements after taking the medication 125. The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. Which equipment should be kept at the bedside? B. A torque wrench 126. An infant weighs 7 pounds at birth. The expected weight by 1 year should be: D. 21 pounds 127. A client is admitted with a Ewing’s sarcoma. Which symptoms would be expected due to this tumor’s location? D. Bone pain 128. The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a serious side effect of this drug? C. WBC 2,000 per cubic millimeter 129. A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis? C. “Describe his usual diet.” 130. The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided? C. Cucumber salad 131. A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period? D. Facilitating perineal wound drainage 132. The nurse is performing discharge teaching on a client with diverticulitis who has been placed on a low-roughage diet. Which food would have to be eliminated from this client’s diet? C. Cooked broccoli 133. The nurse is caring for a new mother. The mother asks why her baby has lost weight since he was born. The best explanation of the weight loss is: D. The baby can lose up to 10% of weight due to meconium stool, loss of extracellular fluid, and initiation of breast-feeding. 134. The nurse is caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common for this diagnosis? C. Diarrhea 135. A removal of the left lower lobe of the lung is performed on a client with lung cancer. Which post-operative measure would usually be included in the plan? A. Closed chest drainage 136. Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as: A. A cephalohematoma 137. The nurse is assisting the RN with discharge instructions for a client with an implantable defibrillator. What discharge instruction is essential? C. “You should use your cellphone on your right side.” 138. A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The nurse should be most careful to monitor the client for which dysrhythmia during this procedure? A. Bradycardia 139. The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period? C. Identification of peripheral pulses 140. A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session? B. “Portions of the procedure will cause pain or discomfort.” 141. The nurse is performing an assessment on a client with possible pernicious anemia. Which data would support this diagnosis? C. A red, beefy tongue 142. A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for: C. Buck’s traction 143. A client with cancer is to undergo an intravenous pyelogram. The nurse should: B. Ask the client to void immediately before the study 144. The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor: B. That is in situ 145. 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?" 146. A nurse is reviewing the laboratory results for a client who is at 29 weeks gestation. For which of the following results should the nurse notify the provider? ANS: Platelet count 95,000 mm3 147. A nurse is performing a dressing change for a client who had abdominal surgery 5 days ago. The nurse notes organs protruding from the incision. Which of the following actions should the nurse take? ANS: Cover the exposed area with sterile, saline-soaked dressings. 148. A nurse is speaking with the adult daughter of a client who has Alzheimer's disease. The daughter states, "I love my dad, but caring for him is wearing me out." Which of the following response should the nurse make? ANS: "Let's discuss how caring for your father is affecting your health. 149. A nurse is contributing to the plan of care for a care for a client who has chest tube connected to a closed drainage system. Which of the following actions should the nurse include in the plan of care? ANS: Maintain the drainage system below the level of the client's chest. 150. A nurse in an acute mental health facility is caring for a client who has borderline personality disorder and reports. "I am going to kill my girlfriend when I get out of here." Which of the following actions should the nurse take? ANS: Notify the client's care team of the threats against the partner 151. A nurse is admitting a client who is at high risk for suicide. Which of the following actions is the nurse's priority? ANS: Search the client's personal belongings 152. A nurse is caring for a client who is 1 day postoperative and is unable to ambulate. Which of the following actions should the nurse take to promote the client's venous return? ANS: Maintain the sequential compression device. 153. A nurse on an acute care unity is collecting data from a schoolage Child who has cystic fibrosis. Which of the following findings is the priority for the nurse? ANS: Reports lack of appetite 154. a nurse working in a provider's office receives a phone call from the parent of a schoolage child who has varicella. The parent asked the nurse when the child can return to school. Which of the following responses should the nurse make? ANS: "When the lesions have scabbed over." 155. 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 of the following actions should the nurse take? ANS: Report the suspected abuse to a appropriate agency. 156. A nurse is collecting data from a middle adult female client who is taking melatonin. Which of the following responses to the med should the nurse expect? ANS: Improved sleep 157. A nurse on a pediatric unit is collecting data from four newly admitted clients. Which of the 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. 158. A nurse is preparing to administer purified protein derivative (PPD) to a client who has suspected TB. Which of the following actions should the nurse plan to take? ANS: Ensure the injection produces a wheal on the skin 159. A client who is diagnosed with Parkinson's disease verbalizes frustration due to increase difficulty with ambulation. Which of the following responses should the nurse take? ANS: Perform active ROM with your arms and legs two times a day. 160. 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." 161. A nurse is caring for a client who is 4 hr postoperative following a total thyroidectomy. Which of the following manifestations should the nurse report to the provider as indicating possible hypocalcaemia? ANS: Tingling of fingers 162. A nurse is caring for a client who has a Penrose drain. To ensure proper placement and functioning of the drain, which of the following should the nurse expect to observe? ANS: The safety pin is present at the distal end of the drain. 163. A community health nurse is helping to reinforce teaching about hepatitis A with a group of employees at a childcare facility. Which of the following characteristics should the nurse identify as an external factor that can impede learning for the participants? ANS: Poor lighting in the learning setting 164. A nurse is observing newly licensed nurse who is providing tracheostomy care for a client. The nurse identifies proper performance of the procedure when the newly licensed nurse selects which of the following solutions to clean the inner cannula? ANS: Hydrogen peroxide 165. A nurse is caring for a client who has right sided heart failure. The client's partner expresses concern the client will die. Which of the following responses should the nurse make? ANS: "It is difficult to see someone so sick. What have you been told about your partner's prognosis?" 166. A nurse is reinforcing discharge instructions with the parent of an infant who has rotavirus. which of the following statements by the parent indicates an understanding of the teaching? ANS: "I will apply diaper cream to my baby's skin during each diaper change." 167. A nurse observes an AP providing care to a child who is in skeletal traction. Which of the following action requires intervention? c) Placing weights as a child’s bed 168 A nurse is planning to delegate to an AP the fasting blood glucose testing for a client who has diabetes mellitus. Which of the following action should the nurse take? a) Determine if the AP is qualified to perform the test. 169 A nurse is assessing client brought to the hospital psychiatric emergency services by a law enforcement officer. The client has disorganized, incoherent speech with loose associations and religious content. You should recognize the signs and symptoms as being consistent with which of the following? b) Schizophrenia 170. A nurse is caring for a child who has infectious mononucleosis.. Which of the following findings are associated with this diagnosis? Select all that apply a) splenomegaly c) Malaise e) Sore throat 171 Nurse is performing dressing change for client was a sacral wound using negative pressure wound therapy. Which The following actions should the nurse take first? d) Determine pain level 172. A nurses caring for client recovery from the bowel surgery who has nasogastric tube connected to low intermittent suction. Which the following assessment findings should indicate to the nurse that the NG tube may not be functioning properly? c) Abdominal rigidity 173. A nurse is preparing to administer TPN with added fat supplements to a client who has malnutrition. Which of the following action should the nurse take? b) Check for an allergy to eggs 174. A charge nurse is discussing the use of applying ice to a client’s injured knee with a newly licensed nurse. Which of the following should the nurse identify as a benefit? (A/C?) c) Decreased capillary permeability 175 Nurse is developing discharge care plans for client has osteoporosis. To prevent injury the nurse should instruct the client to a) Perform weight bearing exercises 176 A nurse on acute med-surgical unit is performing assessments on a group of clients. Which is highest priority? a) The client has surgical hypoparathyroidism and positive Trousseau’s sign 177 Nurses caring for a client was congestive heart failure. Which of the following prescriptions for the provider should the nurse anticipate? c) Give the client enalapril 2.5 mg PO twice daily 178 A nurse is caring for a client who has a prescription for sertraline to treat depression. Which of the following statements by the client indicates an understanding of the medication treatment plan? c) I understand I may experience difficulty sleeping on this medication 179. A nurse has been caring for a female client who has bruises on her arms that she explains are a result of physical abuse by her husband. The client states, “I don’t know how much longer I can take this, but I’m afraid he’ll really hurt me if I leave. “Which of the following is an appropriate nursing intervention?” b) Help the client to recognize the signs of escalation of abuse behavior 180 A client was having suicidal thoughts tells the nurse “It just does not seem worth it anymore. Why not end my misery?” Which of the following responses for the nurses appropriate? b) Do you have a plan to end your life?