Complete Updated ATI Comprehensive Exit Exam | Updated Latest 2025/26 .

ATI Comprehensive Exit Exam 1. A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take a. Ensure the state health department has been notified b. Administer antitoxin c. Educate the family to avoid sharing personal belongings d. Assess for skin necrosis 2. A nurse is caring for a client who has been admitted to the hospital. Select 5 actions the nurse should take. a. Provide frequent rest periods for the client b. Restrict the client’s sodium intake. c. Advise the client to avoid the use of soap and alcohol-based lotions d. Instruct the client to avoid blowing their nose forcefully e. Assess the client’s level of orientation f. Place the client on a low carbohydrate diet g. Place the client under contact isolation 3. A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actions should the nurse perform first? a. Administer an antiemetic medication. b. Evaluate functioning of the suction device. c. Provide oral hygiene care. d. Replace the NG tube. 4. While performing a routine assessment, a nurse notices fraying on the electrical cord of a client's continuous passive motion (CPM) device. Which of the following actions should the nurse take first? a. Initiate a requisition for a replacement CPM device. b. Report the defect to the equipment maintenance staG. c. Remove the device from the room. d. Ensure the device inspection sticker is current. 5. A nurse is creating a plan of care for a female client who has recurrent urinary tract infections. Which of the following interventions should the nurse include in the plan? a. Wear loose-fitting underwear. b. Take a bubble bath after intercourse. c. Drink four 240 mL (8 02) glasses of water each day. d. Void every 5 to 6 hr during the day. 6. A nurse is caring for a newborn. The patient is at risk for developing? Vital Signs 0630 à Newborn delivered via cesarean birth under spinal anesthesia at 0630. Amniotic fluid clear. 0631à 1-min Apgar score 7 0636 à 5-min Apgar score 9Newborn transferred to nursery. 0640 à Temperature 36.7° C (98.1° F), HR 154/min RR 68/min, BP 72/48 with mild grunting. Weight 4200 gm (9 Ib 4 02), head circumference 35.5 cm (14in)0650 à HR 156/min, RR 72/min, with mild grunting 0700 à Temperature 37° C (98.6° F) HR 156/min, RR 76/min, with moderate grunting and mild intercostal retractions. a. Hypoglycemia b. Bronchopulmonary dysplasia c. Transient tachypnea of the newborn d. Tachycardia 7. A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution? a. Remove the cap and place it sterile side up on a clean surface. b. Place sterile gauze over areas of spilled solution within the sterile field. c. Hold the bottle in the center of the sterile field when pouring the solution. d. Hold the irrigation solution bottle with the label facing away from the palm of the hand. 8. A nurse is caring for an infant who has gastroenteritis. Which of the follow- ing assessment findings should the nurse report to the provider? a. Pale and a 24-hr fluid deficit of 30 mL b. Sunken fontanels and dry mucous membranes c. Decreased appetite and irritability d. Temperature 38° C (100.4° F) and pulse rate 124/min 9. A nurse is conducting health promotion education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching? a. Hypertension b. Fibromyalgia c. Renal calculi d. Fibrocystic breast disease 10. A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching? a. "I can continue to take St. John's wort while taking this medication." b. "I know it will be a couple of weeks before the medication helps me feel better." c. "I expect this medication to raise my blood pressure." d. "I should take this medication on an empty stomach." 11. A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture? a. Position a pillow under the client's knees. b. Place a towel roll under the client's neck. c. Align a trochanter wedge between the client's legs. d. Apply an orthotic to the client's foot. 12. A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following interventions should the nurse anticipate?a. Initiate continuous bladder irrigation. b. Administer a fluid bolus. c. Clamp the catheter tubing for 30 min. d. Obtain a urine specimen for culture and sensitivity. 13. A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the client's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin? a. Fibrinogen level b. aPTT c. INR d. Platelet 14. A nurse is assessing a client who is taking haloperidol and is experiencing pseudoparkinsonism. Which of the following findings should the nurse document as a manifestation of pseudo-parkinsonism? a. Serpentine limb movement b. ShuGling gait c. Nonreactive pupils d. Smacking lips 15. A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis following a stroke. Which of the following actions by the nurse best promotes communication among staW caring for the client? a. Posting swallowing precautions at the head of the client's bed b. Noting changes in the treatment plan in the client's medical record c. Recording the client's progress in the nurses' notes d. Having interdisciplinary team meetings for the client on a regular basis 16. A nurse is caring for a 2-year-old toddler. Which of the following food choices should the nurse recommend to promote independence in eating? a. Banana slices b. Grapes c. Hot dog d. Popcorn 17. A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take? a. Act as a liaison between the facility and the media. b. Recommend to the provider specific acute care clients for discharge. c. Determine the medical needs of incoming clients through the emergency department. d. Call in additional medical-surgical unit nursing care staG. 18. A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first? a. A client who is scheduled for a procedure in 1 hr b. A client who received a pain medication 30 min ago for postoperative pain c. A client who was just given a glass of orange juice for a low blood glucose level d. A client who has 100 mL of fluid remaining in his IV bag O19. A nurse is performing postmortem care for a recently deceased client prior to the client's family visit. Which of the following actions should the nurse plan to take? a. Cross the client's arms across their chest. b. Hold the client's eyes shut for a few seconds. c. Place the client in a high-Fowler's position. d. Remove the client's dentures from their mouth. 20. A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices." Which of the following responses is the priority for the nurse to state? a. "What are the voices telling you?" b. "I realize the voices are real to you, but | don't hear anything." c. "Have you taken your medication today?" d. "How long have you been hearing the voices?" 21. A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following findings as an indication that the medication has been eWective? a. Increased blood pressure b. Weight loss c. Decreased inflammation d. Decreased pain 22. A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) - Apply suction while rotating the catheter - Rinse the catheter to remove secretions. - Don sterile gloves. - Insert the catheter during the client's inspiration. - Turn on the suction and set the pressure 1) à Turn on the suction and set the pressure. 2) à Don sterile gloves. 3) à Insert the catheter during the client's inspiration. 4) à Apply suction while rotating the catheter. 5) à Rinse the catheter to remove secretions. 23. A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure. Which of the following actions should the nurse take? a. Send the unsigned informed consent form to the facility's risk manager. b. Determine if the client's health care surrogate is aware of the risks and benefits of the procedure. c. Ensure that the client's family supports the provider's decision for surgery. d. Determine if the procedure is medically necessary for the client. 24. A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make? Oa. "I can start the medication 30 minutes earlier." b. "I can adjust the time and schedule for when it's convenient for you." c. "I can infuse the medication at a faster rate." d. "I have up to 2 hours after the usual schedule time to give you this medication." 25. A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take? a. Document the client's behavior prior to being placed in seclusion. b. Assess the client's behavior once every hour. c. OGer fluids every 2 hr. d. Discuss with the client his inappropriate behavior prior to seclusion. 26. A nurse is caring for an adolescent who has hyperthermia. Which of the following actions should the nurse take? a. Administer oral acetaminophen. b. Cover the adolescent with a thermal blanket. c. Submerge the adolescent's feet in ice water. d. Initiate seizure precautions. 27. A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make? a. "I cannot be a witness for your consent to donate." b. "You must be at least 21 years of age to become an organ donor." c. "Your desire to be an organ donor must be documented in writing." d. "Your name cannot be removed once you are listed on the organ donor list." 28. A parish nurse is leading a support group for clients whose family members have committed suicide. Which of the following strategies should the nurse plan to use during the group session? a. Encourage clients to establish a timeline for their own grieving process. b. Initiate a discussion with clients about ways to cope with changes in family dynamics c. Assist clients in identifying ways suicide could have been prevented. d. Discourage clients from sharing negative aspects of their relationship with the deceased persons. 29. A nurse is developing a care plan for a client who is in Buck's traction and is scheduled for surgery for a fractured femur of the right leg. Which of the following interventions should the nurse delegate to an assistive personnel? a. Ask the client to describe her pain. b. Check the client's pedal pulse on the right leg. c. Observe the position of the suspended weight. d. Remind the client to use the incentive spirometer. 30. A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel (AP) telling the client, "If you don't eat, I'll put restraints on your wrists and feed you." The nurse should intervene and explain to the AP that this statement constitutes which of the following torts? a. Battery b. Assaultc. Negligence d. Malpractice 31. A nurse is caring for a client who has been admitted to the antepartum unit. Click to highlight the findings that require follow-up? a. Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation b. Cervical exam indicates 2cm, 50% eGaced, 0-station c. Uterine contractions 8 minutes, palpate strong, duration 30- seconds d. Client reports lower back pain and pinkish vaginal discharge 32. A nurse is caring for a client who has been admitted to the antepartum unit. Complete the sentence! - Day 1 0900: Admission: Temp 38.4° C (101.1° F), HR 92/min, RR18/min, BP 130/78 mm HgPre-pregnancy BMI 27.6 Current BMI 29.9 Preeclampsia Abruptio placenta Preterm labor Rh incompatibility - Day 2 Client reports lower back pain and pinkish vaginal discharge. Uterine contractions every 8 minutes, palpate strong, duration 30 seconds. FHR base- line 145, minimal variability. Cervical exam indicates 2 cm, 50% eGaced, 0 station. Membranes intact. CBC and urinalysis collected and sent to lab. BMI Blood Pressure Blood Type Previous Preterm Birth a. The nurse should recognize the client is experiencing Preterm labor due to Previous Preterm Birth 33. A nurse is caring for a client who has been admitted to the antepartum unit. Select 2 complications that the client is at risk for developing? - Day 1 0900: Client reports lower back pain and pinkish vaginal discharge. Uterine contractions every 8 minutes, palpate strong, duration 30 seconds. FHR baseline 145, minimal variability. Cervical exam indicates 2 cm, 50% eWaced, 0 station. Membranes intact. CBC and urinalysis collected and sent to lab. - Day 2 30-year-old client at 33 weeks’ gestation, Gravida 4 Para 3 Maternal blood type: Rh+ Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks’ gestation. NKA - Day 3 Temperature 38.4° C (101.1° F) HR 92/min, RR18/min BP 130/78 mm, HgPre-pregnancy BMI 27.6Current BMI 29.9 a. Disseminated intravascular coagulationb. Sepsis c. Preeclampsia d. Seizures e. Placenta previa f. Preterm prelabor rupture of membranes (PROM) 34. A nurse is caring for a client who has been admitted to the antepartum unit. For each potential provider's prescription, click to specify if the potential prescription is anticipated or unanticipated for the client. - Day 1 0900: Client reports lower back pain and pinkish vaginal discharge. Uterine contractions every 8 minutes, palpate strong, duration 30 seconds. FHR baseline 145, minimal variability. Cervical exam indicates 2 cm, 50% eWaced, 0 station. Membranes intact. CBC and urinalysis collected and sent to lab. - Day 2 30-year-old client at 33 weeks’ gestation, Gravida 4 Para 3 Maternal blood type: Rh+ Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks’ gestation. NKA - Day 3 Temperature 38.4° C (101.1° F) HR 92/min, RR18/min BP 130/78 mm, HgPre-pregnancy BMI 27.6Current BMI 29.9 Anticipated a. Limit fluid intake to 3,000 mL/day (Anticipated) b. Maintain bed rest with bathroom privileges (Anticipated) c. Administer betamethasone. (Anticipated) d. Administer terbutaline (Anticipated) Unanticipated e. Administer oxytocin (Unanticipated) f. Place client in supine position. Limit fluid intake to 3,000 mL/day. g. Place client in supine position (Unanticipated) 35. The nurse continues care for the client. Which of the following actions should the nurse take a. Urine Culture b. Obtain provider prescription for antibiotics c. Obtain provider prescription for phenazopyridine 36. The nurse continues care for the client. Click to highlight the findings that indicate improvement in the client’s condition a. Client rates lower back pain a 0 on a scale from 0 1o 10 b. Reports no vaginal discharge c. No uterine contractions noted d. No further reports of burning with urination e. Platelet count 188,000 (150,000-400,000) f. WBC 12,000 (5,000-10,000) g. Temp 37.1(98.7) h. BP 120/7837. A nurse is teaching a client who has a new diagnosis of diabetes mellitus about foot care. Which of the following instructions should the nurse include in the teaching? a. Soak feet twice daily. b. Round the edges of toenails when trimming. c. Use moisturizing lotion between the toes. d. Wear clean cotton socks every day. 38. A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take? a. Instruct the client to lift her chin when swallowing. b. Talk with the client during her feeding. c. Sit at or below the client's eye level during feedings. d. Discourage the client from coughing during feedings. 39. A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect? a. Polyuria b. Hypotension c. Weight loss d. Hematuria 40. A nurse is caring for a client whose partner recently died. The nurse sits with the client to provide comfort. Which of the following ethical principles is the nurse demonstrating? a. Fidelity b. Veracity c. Autonomy d. Beneficence 41. A nurse in an emergency department is caring for a child who reports being sexually abused by a family member. Which of the following actions should the nurse take? a. Use leading statements to obtain information from the child. b. Ensure that multiple nurses are present for the physical examination. c. Explain to the child what will happen when the abuse is reported. d. Reassure the child that no one will be told about the abuse. 42. A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention? a. Using an electronic messaging system to remind clients when to take medications b. Educating clients about contraindications to specific immunizations c. Helping clients understand health screenings covered by their insurance plans d. Providing clients with information about the benefits of exercise 43. A nurse is caring for a client who has given informed consent for electroconvulsive therapy. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate?" a. Most people who have this procedure feel better following the treatment." b. "Your doctor wouldn't have ordered this treatment unless it was necessary." c. "It's okay to be nervous before this treatment." d. "You don't have to go through with the treatment." O44. A nurse is teaching a new parent about breastfeeding her 2-week-old infant. Which of the following statements by the parent indicates an under- standing of the teaching? a. "After 5 to 10 minutes when the breast is emptied, my baby should be removed from the breast." b. "Manually expressing my milk will decrease my milk supply." c. "My baby should always start on the same breast when feeding." d. "The more my baby is at the breast sucking, the more milk I will produce." 45. A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take? a. Evaluate the client's ability to help with repositioning. b. Reposition the client without the use of assistive devices. c. Raise the side rails on both sides of the client's bed during repositioning. d. Discuss the client's preferences for determining a repositioning schedule. 46. A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching? a. "I can go jogging after 2 weeks." b. "I should bend at the waist when putting on my shoes."" c. “I can lift objects that are less than 10 pounds." d. "I can resume activities, such as sewing." 47. A nurse is providing discharge teaching about home care of a surgical incision to a client who speaks a diWerent language from the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take? a. Speak slowly when talking to the interpreter. b. Pause in the middle of sentences. c. Speak directly to the client. d. Use gestures to convey meaning. 48. A nurse is providing teaching to a client who has a new prescription for enoxaparin. Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin? a. Ibuprofen b. Naproxen sodium c. Acetaminophen d. Aspirin 49. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first? a. A client who has epidural analgesia and weakness in the lower extremities b. A client who has a hip fracture and a new onset of tachypnea c. A client who has sinus arrhythmia and is receiving cardiac monitoring d. A client who has diabetes mellitus and an HbA1c of 6.8% 50. A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for cyanosis? O O O Oa. Sacrum b. Palms of the hands c. Shoulders d. Area of trauma 51. A charge nurse is teaching new staW members about factors that increase a client's risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence? a. A history of being in prison b. Male gender c. Experiencing delusions d. Previous violent behavior 52. A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider? a. Temperature 37.4° C (99.3° F) b. Early decelerations in the FHR c. FHR baseline 170/min d. Contractions lasting 80 seconds 53. A quality control nurse is reviewing medication prescriptions for a group of clients. Which of the following medication prescriptions should the nurse identify as being complete? a. Tetracycline 200 mg PO b. Epoetin alfa 150 units/kg three times weekly c. Digoxin 0.25 mg PO daily d. Cimetidine PO twice daily 54. A nurse is caring for a client in the emergency department. Complete the diagram below. a. Potential Condition: Brief Psychotic Disorder b. Action 1: Have you been sick recently c. Action 2: Reduce External Stimuli d. Parameter 1: Suicide Risk e. Parameter 2: Ability to self care 55. A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staW to evacuate first? a. A client who is ambulatory and receiving oxygen b. A client who has a fracture and is in balance suspension traction c. A client who is bedridden and wears a hearing aid d. A client who uses a wheelchair and is confused 56. A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) a. Give the client one simple direction at a time. b. Refute the client's delusions using logic. c. Allow the client to choose among a variety of activities each day. d. Reinforce orientation to time, place, and person. e. Establish eye contact when communicating with the client. O O57. A nurse is providing discharge teaching to the partner of a client who has a tracheostomy. Which of the following information should the nurse include in the teaching? a. How to operate the portable suction machine b. How to secure the tracheostomy tube with ties at the back of the neck c. How to change the non-disposable tracheostomy tube daily d. How to change the tracheostomy dressing using clean technique 58. A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse? a. Suggest rinsing his mouth with an alcohol-based mouth wash. b. Provide humidification of the room air. c. OGer the client saltine crackers between meals. d. Instruct the client on the use of esophageal speech. 59. A public health nurse working in a rural area is developing a program to improve health for the local population. Which of the following actions should the nurse plan to take? a. Launch a media campaign to increase awareness about industrial pollution. b. Have a nurse from outside the community provide health lectures at the county hospital. c. Encourage rural residents to focus health spending on tertiary health interventions. d. Provide anticipatory guidance classes to parents through public schools. 60. A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect? a. Drooling b. Malaise c. Tinnitus d. Rhinorrhea 61. A nurse in an emergency department is caring for a client. Click to highlight the findings that require a follow up a. Client present for evaluation of severe pain in upper abdomen that radiates into his back b. States pain began approximately 12 hr ago and is worse when he is supine or after he eat c. Sclera noted to be yellow d. Abdomen firm, bowel sounds hypoactive e. Client guards abdomen and grimaces during palpations 62. A nurse in an emergency department is caring for a client. For each finding, click to specify if the finding is consistent with pancreatitis or peritonitis a. Peritonitis à Bloody stool b. Pancreatitis à Hyperbilirubinemia c. Both à Elevated WBC, Abdominal Pain 63. A nurse in an emergency department is caring for a client. Complete the following sentence below a. The nurse should first address the client’s Lung Sounds followed by the patient’s Blood Pressure 64. A nurse in an emergency department is caring for a client. Click to specify if the prescription is anticipated or contraindicated Oa. Anticipated à Administer famotidine 20 mg via intermittent IV infusion twice daily. b. Anticipated à Administer lactated Ringer's 1 L via IV bolus c. Anticipated à Insert a nasogastric tube and maintain low intermittent suction. d. Contraindicated à Insert an indwelling urinary catheter 65. A nurse in an emergency department is caring for a client. The nurse is providing teaching to the client about self-care. Select 3 statements the nurse should include in the teaching? a. "Notify your provider if you experience vomiting or diarrhea." b. "You should eat foods that are low in fat." c. "You should eat foods high in protein." d. “Limit alcohol intake to no more than one drink per day” e. “You should drink beverages that contain caGeine” 66. A nurse in an emergency department is caring for a client. The nurse is preparing to discharge the client. Which of the following statements by the client indicates an understanding of the discharge teaching? a. "I will eat small, frequent meals," b. “I should expect my bowel movements to be pale in color." c. "I will notify my provider if my urine is dark." d. “I will limit my morning coGee to no more than two cups” e. “I will eat fish for dinner at least twice per week” 67. A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following actions should the nurse plan to take? a. Position the client on the aGected side for 4 hr following the procedure. b. Instruct the client to avoid coughing during the procedure. c. Inform the client that he will be NPO for 6 hr prior to the procedure. d. Place the client in the prone position during the procedure 68. A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect? a. Head circumference exceeds chest circumference b. Palpable fontanels c. Natural loss of deciduous teeth d. Nontender, protruding abdomen 69. A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include? a. Remove the client restraint every 4 hr. b. Document the client's condition every 15 min. c. Request a PRN restraint prescription for clients who are aggressive d. Attach the restraint to the bedside falls. 70. A nurse in a PACU is transferring care of a client to a nurse on the medical- surgical unit. Which of the following statements should the nurse include in the hand-oW report? a. The estimated blood loss was 250 milliliters. b. The client is a member of the board of directors." c. There was a total of 10 sponges used during the procedure. d. The client was intubated without complications." O O71. A nurse in an emergency department is caring for a client who has a closed head injury. Which of the following actions should the nurse take first? a. Determine the client's Glasgow Coma Scale score. b. Insert an foley urinary catheter for the client c. Administer mannitol IV bolus to the client. d. Prepare the client for an MRI of the brain. 72. A nurse in an emergency department is caring for a client following a motor vehicle crash. The client's Glasgow coma scale rating is 15. Which of the following findings should the nurse expect? a. The client is oriented times three. b. The client opens eyes to sound. c. The client is unable to obey commands. d. The client withdraws from pain. 73. A nurse is reviewing a client's cardiac rhythm strips and notes a constant P.R. interval of 0.35 seconds. Which of the following dysrhythmias is the client displaying? a. First-degree atrioventricular block b. Complete heart block c. Premature atrial complexes d. Atrial fibrillation 74. A nurse is caring for a client who has end-stage kidney disease. The client's adult child asks the nurse about becoming a living kidney donor for their parent. Which of the following conditions in the child's medical history should the nurse identify as a contraindication to the procedure? a. Amputation. b. Osteoarthritis. c. Hypertension d. Primary glaucoma 75. A nurse is caring for a client. For each assessment finding, click to specify if the finding is consistent with ulcerative colitis, diverticulitis, or Crohn's disease? a. Ulcerative colitis à Fever, Weight loss, Diarrhea b. Diverticulitis à Fever, Anemia, Diarrhea c. Crohn’s à Fever, Steatorrhea, Anemia, Weight loss, Diarrhea 76. A case manager is meeting with a client who asks about using alternative therapies to manage her rheumatoid arthritis. Which of the following statements should the nurse make? a. We can review some information to help you select a safe alternative practitioner b. If there are therapies available to you, your provider will tell you about them. c. Feel free to try whatever therapies that fit within your personal belief system. d. I'm sure you can find alternative remedies through an online support group." 77. A nurse is preparing to obtain a health history from a client who is on bed rest. Which of the following positions should the nurse take to place the client at ease? a. Sit in a chair next to the bed. b. Stand at the side of the bed. c. Sit on the bed next to the client. O ↑ O Od. Stand at the foot of the bed. 78. A nurse is caring for a newborn whose mother was taking methadone during her pregnancy. Which of the following findings indicates the newborn is experiencing withdrawal? a. Bulging fontanels b. Acrocyanosis c. Bradycardia d. Hypertonicity 79. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The bag has 20 mL remaining to infuse, but a new bag is not readily available. Which of the following actions should the nurse take? a. Administer dextrose 10% in water. b. Give 500 mL of Lactated Ringer’s solution. c. Slow the TPN infusion rate. d. Temporarily discontinue the infusion. 80. A nurse is auscultating for crackles on a client who has pneumonia. Which of the following anterior chest wall locations should the nurse auscultate? a. à C lower lungs! 81. A nurse is providing teaching about immunizations to a client who is pregnant. Which of the following statements should the nurse include in the teaching? a. “The immunization for varicella should be given at least 1 month prior to delivery.” b. “You can receive the rubella immunization during the third trimester of pregnancy." c. “The hepatitis B immunization should not be obtained until after you finish breastfeeding” d. “You can receive the immunization for influenza at any time during your pregnancy." 82. A nurse is planning teaching for a client and their family about home oxygen therapy. Which of the following information should the nurse plan to include in the teaching? a. Apply petroleum jelly to soothe the mucous membranes. b. Use synthetic fabrics for the client's bedding c. Clean the equipment with an alcohol-based cleaning product. d. Avoid using nail polish remover around the client. 83. A nurse is instructing a school-age child who has asthma about the use of a peak expiratory flow meter. Which of the following instructions should the nurse include in the teaching? a. Place tongue on the mouthpiece of the meter. b. Maintain a semi-Fowler's position during testing. c. Record the average of the readings. d. Blow into the meter as hard and quickly as possible. 84. A nurse is caring for a client who is 12 hr postpartum and has a third-degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer? a. Bisacodyl 10 mg rectal suppository b. Magnesium hydroxide 30 mL PO c. Famotidine 20 mg PO d. Loperamide 4 mg PO85. A nurse is providing discharge teaching to the parents of a toddler who has cystic fibrosis. Which of the following instructions should the nurse Include? a. "Perform chest percussion and postural drainage at least twice daily." b. "Restrict intake of foods that contain gluten.” c. "Administer pancreatic enzymes on an empty stomach.” d. "Use a nebulizer to administer a bronchodilator following airway clearance therapy." 86. A nurse is planning care for a client who has a prescription for a bowel training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care? a. Increase the amount of refined grains in the client's diet. b. Provide the client with a cold drink prior to defecation. c. Administer a cathartic suppository 30 min prior to scheduled defecation times. d. Encourage a maximum fluid intake of 1,500 mL per day. 87. A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port? a. An Angio catheter b. A 25-gauge needle c. A butterfly needle d. A non-coring needle 88. A nurse is assessing a client immediately following a cardiac catheterization. The nurse should notify the provider for which of the following findings? a. Report of discomfort at the insertion site b. Heart rate 90/min c. Bounding pulses in the aGected extremity d. Hematoma over the insertion site 89. A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. For which of the following therapeutic eWects should the nurse monitor the client? a. Deep tendon reflexes 2+ b. Pulse rate 100/min c. Urine output 20 mL/hr d. 1+ proteinuria via urine dipstick 90. A nurse is teaching a newly licensed nurse about caring for clients in the emergency department. Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly? a. Use a face shield with a mask when providing care to the client. b. Tell the client, "You seem to be very upset." c. Engage the panic alarm. d. Initiate seclusion protocol. 91. A nurse is caring for a client who is admitted to the medical surgical unit. The nurse reviews the client’s laboratory findings and vital signs. Select 5 findings that require immediate follow up? a. Stool results O Ob. Hemoglobin and hematocrit c. Heart rate d. Current medications e. Blood pressure f. Respiratory rate g. Temperature h. WBC count 92. A nurse is caring for a client who is admitted to the medical-surgical unit. Complete the following sentence? a. The nurse anticipates the client will likely require an endoscopy as evidenced by the client’s stool test results 93. The nurse is obtaining the clients vital signs prior to an endoscopy. Complete the flowing sentence below. a. The nurse should first anticipate the need to obtain IV access and the need to prepare to administer IV fluids 94. The nurse is preparing the client for a blood transfusion. Which of the following actions should the nurse take? Select all that apply. a. Have a second nurse confirm the information on the blood label b. Insert a large-bore IV catheter. c. Witness the client signing a consent for transfusion. d. Flush the transfusion tubing with dextrose 5% in water. e. Explain to the client that transfusion reactions are not serious. 95. The nurse reviews the entries in the medical record. The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client. Indicated à a. Document the blood product transfusion in the client's medical record. b. Stay with the client for the first 15 min of the transfusion. c. Obtain the first unit of packed RBCs from the blood bank. Not indicated à d. Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg. e. Start an IV bolus of lactated Ringer's solution 96. The nurse is assessing the client following the transfusion of 2 units of packed RBCs Click the highlight the findings that indicate improvement in the client's condition to deselect a finding click on the finding again Laboratory Results - WBC count 6,700/33^3 (5,000 to 10,000/33^3) - Hemoglobin 12 g/dl (14 to 18 g/dL) - Hematocrit 36% (40% to 52%) Vital signs - Blood Pressure 112/74 mm Hg - Heart rate 95/min - Respiratory rate 18/min- Temperature 37.5° C (99.5° F) - Oxygen saturation 100% via 2 L/min Assessment General - no distress - HEENT: oropharynx clear, mucous membranes moist and pink - Respiratory: bilateral breath sounds clear - GI: epigastric tenderness to palpation, no rebound tenderness or guarding - Neuro: awake and alert a. Hemoglobin 12 g/dl (14 to 18 g/dL) b. Hematocrit 36% (40% to 52%) c. Blood Pressure 112/74 mm Hg d. Heart rate 95/min e. General – no distress f. HEENT – oropharynx clear and mucus membranes moist and pink 97. A nurse is caring for a client who has a placenta previa. Which of the following findings should the nurse expect? a. Spotting b. Nausea c. Polyhydramnios d. Uterine tenderness 98. A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist's notes. Which of the following responses should the nurse make? a. "Are you not happy with your treatment?" b. "We can provide a copy of your records, but the therapist's notes are not included." c. "Why are you interested in seeing your therapist's notes?" d. “I don't think you will benefit from reviewing your therapist's notes right now” 99. A nurse is preparing to administer a medication that is available in a glass ampule. Which of the following actions should the nurse plan to take? a. The nurse should use a filter needle to withdraw the medication. b. The nurse should break the neck of the ampule toward their body. c. The nurse should use the same needle to draw up and inject the client. d. The nurse should dispose of the ampule in the trash can. 100. A nurse in a provider's oWice is caring for a client who asks about using acupuncture to manage his osteoarthritis pain. The nurse should identify which of the following conditions as a contraindication for receiving this treatment. a. A) Hypertension b. Obesity c. Hypothyroidism d. Herpes zoster 101. A nurse is admitting a client who is hesitant to create advance directives due to concerns about aWording legal representation. Which of the following statements should the nurse make?a. "We can initiate medical care until you get legal assistance in preparing your advance directives." b. "Advance directives can be signed without legal representation." c. "Advance directives can be a verbal agreement between you and your provider until legal review can be obtained." d. "A social worker will assist you to find aGordable legal representation." 102. A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse plan to take? a. Choose a vein that is palpable and straight. b. Elevate the client's arm prior to insertion. c. Apply a tourniquet below the venipuncture site. d. Select a site on the client's dominant arm. 103. A nurse in an emergency department is assessing an adolescent who has conduct disorder. Which of the following questions is the priority for the nurse to ask the client? a. "How do you manage your behavior?" b. "Do you have a criminal record?" c. "How do you get along with your peers at school?" d. "Do you have thoughts of harming yourself?" 104. A nurse is caring for a school-age child who is postoperative and received morphine via IV bolus for pain 10 min ago. Which of the following findings is the nurse's priority? a. Constipation b. Sedation c. Bradypnea d. Euphoria 105. A nurse is planning to teach a client about taking prednisone. Which of the following instructions should the nurse include? a. Monitor for weight loss. b. Increase dietary calcium. c. Take on an empty stomach. d. Schedule dosage at bedtime. 106. A nurse is caring for a client who is receiving penicillin G via intermittent IV piggyback. Which of the following actions should the nurse take? a. Infuse the medication over 10 min. b. Instruct the client to notify the provider if diarrhea develops. c. Refrigerate the medication after reconstitution. d. Check the client for a sulfa allergy. 107. A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care? a. Give cromolyn nebulized solution every 8 hr. b. Administer analgesics on a scheduled basis for the first 24 hr. c. Apply a warm compress to the operative site once daily. d. OGer small amounts of clear liquids 6 hr following surgery. O108. A nurse in an acute care mental health facility is participating in a medication education group. The leader of the group uses a laissez-faire leadership style. Which of the following actions should the nurse expect from the leader during the session? a. The leader allows the group to discuss whatever they would like to regarding their medications. b. The leader encourages group members to remain silent until questions are called for. c. The leader has group members vote on what they would like to learn about during the session. d. The leader lectures about medication's adverse eGects to the group members. 109. A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take? a. Place the client in a side-lying position prior to assessing the fetal heart rate. b. Measure the fundal height to determine the placement of the ultrasound stethoscope. c. Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate. d. Perform Leopold maneuvers prior to auscultating the fetal heart rate. 110. A nurse is teaching a client who has atrial fibrillation and is to start taking dabigatran. Which of the following statements by the client indicates an understanding of the teaching? a. "I should keep the medication in the original container." b. "I should replace any unused medication every 6 months." c. "I can store the medication in the refrigerator. d. "I can crush the medication and mix with applesauce." 111. A charge nurse is observing a conflict between two nurses who both insist that the charge nurse favors the other when making assignments. Which of the following conflict-resolution strategies should the charge nurse use? a. Encourage collaboration between the two nurses when making the assignments. b. Ask each nurse to take turns making the assignments. c. Tell the nurses that the assignments will be more equitable in the future. d. Arrange for the nurses to have as few shifts together as possible. 112. A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate the eWectiveness of the procedure? a. Examine for leakage at the site of the procedure. b. Compare the client's current weight with pre-procedure weight. c. Confirm that the client is able to urinate. d. Check the client's serum albumin levels. 113. A nurse is reviewing the laboratory data of a client who received 2 units of packed RBCs. Which of the following laboratory findings should the nurse expect following the transfusion? a. Increased platelets b. Increased Hct c. Decreased Hgb d. Decreased WBC count O O114. A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings requires follow-up care? a. A client who is taking bumetanide and has a potassium level of 3.6 mEq/L b. A client who is scheduled for a colonoscopy and is taking sodium phosphate c. A client who is taking warfarin and has an INR of 1.8 d. A client who received a Mantoux test 48 hr ago and has an induration 115. A nurse is caring for a client who has a prescription for a peripheral IV catheter. After puncturing the skin with the vascular access device and noting a blood return in the flashback chamber. Which of the following actions should the nurse perform next? a. Flush the catheter with saline. b. Retract the stylet. c. Advance the catheter into the vein. d. Release the tourniquet. 116. A nurse is providing preoperative teaching to a client about promoting circulation during the postoperative period. Which of the following instructions should the nurse include? a. "Remain on bed rest for 24 hours following the procedure." b. "Participate in range-of-motion exercises." c. "Use an incentive spirometer every 4 hours." d. "Place a pillow under your knees while in bed." 117. A nurse is teaching a client who has chronic pain about avoiding constipation from opioid medications. Which of the following information should the nurse include in the teaching? a. Take mineral oil at bedtime. b. Decrease insoluble fiber intake. c. Drink 1.5 L of fluids each day. d. Increase exercise activity. 118. A nurse is teaching a client who has rheumatoid arthritis about illness management. Which of the following instructions should the nurse include in the teaching? a. Apply cold packs directly on the skin of the aGected joints. b. Administer biological response modifiers to prevent infection. c. Take a hot shower in the morning to decrease stiGness. d. Cluster physical activities during the day. 119. A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching as an example of malpractice? a. Documenting communication with a provider in the progress notes of the client's medical record b. Placing a yellow bracelet on a client who is at risk for falls c. Leaving a nasogastric tube clamped after administering oral medication d. Administering potassium via IV bolus 120. A nurse is providing teaching about the use of crutches using a three- point gait to a client who has a tibia fracture. Which of the following actions by the client indicates an understanding of the teaching? a. Stepping with his aGected leg first when going upstairs O O similarb. Moving both crutches with the stronger leg forward first c. Supporting his body weight while leaning on the axillary crutch pads d. Positioning both hands on the grips with his elbows slightly flexed 121. A nurse in an emergency department is caring for a client. Click to highlight the finding the nurses should report to the provider. Vital Signs a. Blood pressure 142/96 mm Hg b. Temperature 36.7° C (98° F) c. Heart rate 96/min d. Respiratory rate 16/min e. SpO2, 97% on room air Nurses Notes 1200: Nurses Notes a. Client is an 82-year-old male who presents with his adult child for evaluation of right arm pain after a fall. b. Client noted to have several superficial abrasions on right forearm and elbow. c. Also has numerous bruises in various stages of healing on arms and upper chest. d. Client rates pain in right lower forearm an 8 on a 0 to 10 pain scale and is not moving the arm 122. A nurse in an emergency department is caring for a client. For each assessment finding, specify if the finding is an indication of physical maltreatment, neglect, or financial maltreatment a. Client reports having little food à Neglect, Financial maltreatment b. Client has bruises in various stages of healing à Physical maltreatment c. Client wears dirty clothing à Physical maltreatment, Neglect d. Client has no access to bank accounts à Financial maltreatment 123. A nurse in an emergency department is caring for a client. Complete the sentence below. a. The nurse should first address the clients Safety followed up by the clients Pain 124. A nurse in an emergency department is caring for a client. The nurse is preparing to speak to the facility's Social Worker about the client's condition. Select the 5 findings the nurse should plan to include in the report. a. Client reports of lack of food in home b. Numerous bruises in various stages of healing c. Client's avoidance of eye contact d. Client's report of lack of access to bank accounts e. Client’s report of weight loss f. ECG results 125. A nurse in an emergency department is caring for a client. Click to highlight the findings that require immediate follow-up. - Respiratory Findings Respiratory rate 11/min SpO2 94% on room air Lungs clear to auscultation - Musculoskeletal Findings Reports pain worsening in right forearm States right hand is "tingly." Able to move fingers126. A nurse in an outpatient clinic is caring for the client six weeks following surgical repair of a fractured radius. Which of the following information provided by the client indicates improvement? a. The client makes eye contact and smiles when speaking b. The client adult child prepares two meals per day for the client. c. The client clothing is clean and appropriate for the weather. d. The client has gained 1.8 kg (4lb) BMI is 18.9 e. The client receives three baths per week from a home care side f. The client reports frequent toothaches and lack of dental care. 127. A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching? a. I should take antibiotics when I have a virus. b. I can visit my nephew who has chickenpox 5 days after the sores have crusted. c. I can clean my cat's litter box during my pregnancy d. I should wash my hands for 10 seconds with hot water after working in the garden. 128. A nurse is caring for a client who has experienced a stroke and is moving in with their adult child. Which of the following actions should the nurse encourage the client and family to take as they adjust to their new roles? a. Implement firm but flexible boundaries in their relationship. b. Encourage authoritative communication from the adult child, c. Decrease socialization with extended relatives until roles are identified. d. Minimize open discussion regarding the changes to avoid embarrassment. 129. A nurse is assessing a client who has an abdominal incision. Which of the following findings should the nurse report to the provider? a. Pink-tinged coloration on the incisional line b. Mild swelling under the sutures near the incisional line c. Crusting of exudate on the incisional line d. Partial separation of the upper part of the incisional line 130. A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests? a. Platelet count b. Potassium level c. Creatinine clearance d. Prealbumin 131. A nurse is providing nutrition teaching for a client who has hypertension. Which of the following foods should the nurse suggest the client include in their diet? a. Cheese b. Red meat c. Canned black beans d. Fish O132. A nurse in an emergency department is reviewing the medical record of a client who is having an acute myocardial infarction. Which of the following findings places the client at risk if he receives alteplase? a. Family history of malignant. hypertension b. Hip arthroplasty 1 week ago. c. Chronic obstructive pulmonary disease d. Acute renal failure 6 months ago 133. A nurse is caring for a school-age child who is 2 hr postoperative following a cardiac catheterization. The nurse observes blood on the child's dressing. Which of the following actions should the nurse take? a. Apply intermittent pressure 2.5 cm(1in) below the percutaneous skin site. b. Apply continuous pressure 2.5 cm(1in) above the percutaneous skin site. c. Apply continuous pressure 25 cm(1in) below the percutaneous skin site. d. Apply intermittent pressure 2.5 cm (1 in) above the percutaneous skin site. 134. A nurse is planning care for a client who has a prescription for continuous enteral feedings through an NG tube. Which of the following actions should the nurse plan to take? a. Flush the NG tube with 30 mL 0.9% sodium chloride before and after medication. b. Maintain the head of the bed at a 20* angle. c. Advance the rate of the feeding every 2 hr. d. Measure gastric residual volumes every 4 hr. 135. A charge nurse is concerned about a recent increase in facility-acquired catheter infections. Which of the following actions should the nurse take first? a. Meet with providers to discuss measures to decrease the infections. b. Identify possible precipitating factors related to the infections. c. Schedule nursing staG training for infection control procedures. d. Revise the current policy for catheter care 136. A nurse in an outpatient clinic is caring for a client. Complete the diagram below. a. Potential Condition à Osteoarthritis b. Action 1 àInstruct the client to apply topical analgesic c. Action 2 à Instruct the client to apply heat and cold d. Parameter 1 à ESR e. Parameter 2: Lymphadenopathy 137. A charge nurse is delegating care for a group of clients. Which of the following tasks should the charge nurse assign to a licensed practical nurse? a. Complete discharge teaching for a client who has a new diagnosis of diabetes mellitus. b. Complete the Glasgow Coma Scale for a client who has an evolving stroke. c. Perform a sterile dressing change for a client who has an abdominal wound d. Perform an admission assessment for a client who is scheduled for surgery. 138. A nurse is caring for a 2-month-old infant who has heart failure. Which of the following actions should the nurse take? a. Limit oral feedings to 30 min in length b. Check the infant's oxygen saturation every 6 hr. c. Place the infant in the prone position for naps. O Od. Weigh the infant every other day. 139. A nurse is admitting a client to a medical-surgical unit. When performing medication reconciliation for the client, which of the following actions should the nurse take? a. Encourage the client to make his own st after he returns to his home. b. Include any adverse eGects of the medications the client might develop. c. Exclude nutritional supplements from the list of medications the client reports d. Compare new prescriptions with the list of medications the client reports 140. A staW nurse is observing a newly licensed nurse suction a client's tracheostomy. Which of the following actions by the newly licensed nurse requires intervention by the staW nurse? a. Waits for 2 min between suctions b. Encourages the client to cough during suctioning c. Applies suction for 15 seconds d. Insert the catheter without applying suction 141. A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take? a. Assign the child to a negative air pressure room. b. Use droplet precautions when caring for the child. c. Assess the child for Koplik spots. d. Administer aspirin to the child for fever. 142. A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? a. A client who is receiving heparin for deep-vein thrombosis b. A client who has COPD and a respiratory rate of 44/min c. A client who has cancer and a sealed implant for radiation therapy d. A client who is 1 day postoperative following a vertebroplasty 143. A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? a. Swelling of the face b. Bleeding gums. c. Urinary frequency d. Faintness upon rising 144. A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia. a. Chorioamnionitis b. Maternal fever c. Fetal anemia d. Maternal hypoglycemia 145. A nurse is assisting with food selection for a client who follows kosher dietary traditions. Which of the following food choices should the nurse include on the client's food tray? a. Bacon and cheese quiche with milk Ob. Scrambled eggs and toast with milk c. Shrimp salad and tomato soup with milk d. Ham sandwich with milk 146. A nurse is providing discharge teaching to a client who is postoperative following surgery for carpal tunnel syndrome. Which of the following statements by the client indicates an understanding of the teaching? a. "I should not use my aGected hand for 4 to 6 weeks." b. "I will need to keep my hand elevated above my heart for several days." c. "I should expect numbness and tingling in my hand." d. "I can apply heat for the first 24 hours to minimize the pain in my hand." 147. A nurse is planning care for a toddler who has epiglottitis. Which of the following interventions should the nurse include? a. Assess the child for frequent swallowing b. Carefully suction the child's oropharynx to remove secretions. c. Administer pancreatic enzymes with meals. d. Continuously monitor the child's respiratory status. 148. A nurse is assessing a client who is experiencing hypovolemia. Which of the following manifestations should the nurse expect? a. Shortness of breath b. Dizziness c. Epistaxis d. Headache 149. A nurse is caring for a client who has an indwelling urinary catheter. The nurse notes that sediment is present in the urine. Which of the following actions should the nurse take to obtain a sterile urine specimen? a. Disconnect the catheter from the collection tubing. b. Obtain the specimen from the retention port. c. Use the balloon port to obtain the sterile specimen. d. Unclamp the collection port below the bag. 150. A nurse is positioning a client for a cesarean birth. To prevent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take? a. Position the client in reverse Trendelenburg. b. Place a wedge under one of the client's hips. c. Assist the client into the lithotomy position. d. Insert a pillow under the client's knees. 151. A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding? a. Weak femoral pulses b. Frequent nosebleeds c. Upper extremity hypotension d. Increased intracranial pressure152. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? a. Contractions b. Hypertension c. Epigastric pain d. Vomiting 153. A nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse include in the teaching? a. "A nurse will draw blood from your baby's inner elbow." b. "Your baby will be given 2 ounces of water to drink prior to the test." c. "This test should be performed after your baby is 24 hours old." d. "This test will be repeated when your baby is 2 months old." 154. A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan? a. Maintain eye contact with the newborn during feedings. b. Minimize noise in the newborn's environment. c. Swaddle the newborn with his legs extended. d. Administer naloxone to the newborn. 155. A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? a. Administer a bronchodilator after the procedure. b. Perform the procedure prior to meals. c. Perform the procedure twice each day. d. Hold hand flat to perform percussions on the child. 156. A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include? a. "This type of seizure lasts 30 to 60 seconds." b. "This type of seizure can be mistaken for daydreaming." c. "This type of seizure has a gradual onset." d. "The child usually has an aura prior to onset." 157. A charge nurse is teaching a newly licensed nurse about the facility's computerized documentation system. Which of the following information shou the nurse include? a. "Information Technology will install a firewall to secure client information." b. "You will be asked to change your password once per year." c. "Documentation of sensitive material is performed by the charge nurse." d. "You will be given access to the medical records of every client in the facility." 158. A nurse inadvertently administered 160 mg of valsartan PO to a client who was scheduled to receive 80 mg. Which of the following actions is the priority for the nurse to take? a. Evaluate the client for orthostatic hypotension. b. Monitor the client's urine output. c. Obtain the client's laboratory results. d. Check the client for nasal congestion159. A nurse at a community health clinic is planning care for an adolescent who recently learned that she is pregnant and is concerned about her ability to aWord and care for her baby. Which of the following actions should the nurse take? a. Refer the adolescent to