VATI GREEN LIGTH COMPREHENSIVE
FORM A,B,C EXAM QUESTIONS
WITH DETAILED ANSWERS
A nurse is admitting a client who has antisocial personality disorder. Which of the f
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
ollowing client behaviors should the nurse identify as consistent with this disorder?
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
A. Compulsive attention to details
5z 5z 5z 5z
B. Avoids interacting with others
5z 5z 5z 5z
C. Uses others for personal gain
5z 5z 5z 5z 5z
D. Socially awkward in group situations - ANSWERS-
5z 5z 5z 5z 5z 5z 5z
C. Uses others for personal gain
5z 5z 5z 5z 5z
A nurse is interpreting the cardiac rhythm strip of a client who was admitted with s
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
yncope. Which of the following images indicates that the client has atrial fibrillation
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
? - ANSWERS-
5z 5z
A client who has a diagnosis of complete placenta previa is admitted to the labor a
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
nd delivery suite at 36 weeks gestation with contractions 5 min in frequency and 1
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
min in duration. Which of the following actions should the nurse take?
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
A. Rupture the amniotic sac
5z 5z 5z 5z
B. Medicate the client for pain
5z 5z 5z 5z 5z
C. Prepare the client for a cesarean section
5z 5z 5z 5z 5z 5z 5z
D. Perform a vaginal exam - ANSWERS-
5z 5z 5z 5z 5z 5z
C. Prepare the client for a cesarean section
5z 5z 5z 5z 5z 5z 5z
A charge nurse on a pediatric unit is making assignments for a float nurse from th
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
e medical unit. Which of the following clients is appropriate to assign to the float n
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
urse?
A. A 10-year-old client who has pneumonia and is receiving respiratory treatments
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
B. A 4-year-old client who has a Wilms tumor and is receiving chemotherapy
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
C. An 8-month-
5z 5z
old client who is scheduled for a surgical repair of a ventricular septal defect tomor
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
row
D. A 14-year-
5z 5z
old client who is scheduled for discharge today following placement of a Harrington
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
rod - ANSWERS-A. A 10-year-
5z 5z 5z 5z 5z
old client who has pneumonia and is receiving respiratory treatments
5z 5z 5z 5z 5z 5z 5z 5z 5z
A nurse notices smoke coming from a client's room and discovers a fire in the was
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
tebasket. After moving the client to safety, which of the following is the priority acti
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
on?
A. Notify the facility operator.
5z 5z 5z 5z
B. Close the fire doors on the unit.
5z 5z 5z 5z 5z 5z 5z
C. Turn off oxygen sources.
5z 5z 5z 5z
D. Put out the fire with the appropriate extinguisher. - ANSWERS-
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
A. Notify the facility operator.
5z 5z 5z 5z
,A nurse is assessing an infant who has water intoxication. Which of the following fi
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
ndings should the nurse expect?
5z 5z 5z 5z
A. Generalized edema
5z 5z
B. Elevated urine specific gravity
5z 5z 5z 5z
C. Thready pulse
5z 5z
D. Increased hematocrit - ANSWERS-A. Generalized edema
5z 5z 5z 5z 5z 5z
A nurse is discussing the z-
5z 5z 5z 5z 5z
track administration of hydroxyzine with a newly licensed nurse. Which of the follo
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
wing statements indicates the newly licensed nurse understands the purpose of th
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
e technique?
5z
A. This technique prevents injury to the sciatic nerve
5z 5z 5z 5z 5z 5z 5z 5z
B. This technique decreases the risk of subcutaneous infiltration
5z 5z 5z 5z 5z 5z 5z 5z
C. This technique allows a larger amount of medication to be injected
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
D. This technique increases the absorption rate of the drug - ANSWERS-
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
This technique decreases the risk of subcutaneous infiltration
5z 5z 5z 5z 5z 5z 5z
A nurse is creating a plan of care for a client who has anorexia nervosa. Which of
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
the following interventions should the nurse include in the plan?
5z 5z 5z 5z 5z 5z 5z 5z 5z
A. Encourage the client to gain 2.3 kg per week
5z 5z 5z 5z 5z 5z 5z 5z 5z
B. Weigh the client once per week throughout hospitalization
5z 5z 5z 5z 5z 5z 5z 5z
C. Monitor the client for 1 hr after meals
5z 5z 5z 5z 5z 5z 5z 5z
D. Allow the client to choose mealtimes - ANSWERS-
5z 5z 5z 5z 5z 5z 5z 5z
C. Monitor the client for 1 hr after meals
5z 5z 5z 5z 5z 5z 5z 5z
A nurse is planning care for a child who has increased intracranial pressure with a
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5
decrease in level of consciousness. Which of the following interventions should the
z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
nurse include in the plan of care?
5z 5z 5z 5z 5z 5z 5z
A. Perform active range-of-motion exercises
5z 5z 5z 5z
B. Maintain the head at a midline position
5z 5z 5z 5z 5z 5z 5z
C. Suction the airway frequently
5z 5z 5z 5z
D. Perform neurological checks every 4 hrs - ANSWERS-
5z 5z 5z 5z 5z 5z 5z 5z
B. Maintain the head at a midline position
5z 5z 5z 5z 5z 5z 5z
10. A nurse is assessing a client who has delirium due to a febrile illness. Which o
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
f the following findings should the nurse expect?
5z 5z 5z 5z 5z 5z 5z
A. Hallucinations
5z
B. Agnosia5z
C. Bradycardia
5z
D. Aphasia - ANSWERS-A. Hallucinations
5z 5z 5z 5z
A nurse is assessing a client who is receiving enteral feedings via a gastrostomy t
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
ube. The nurse should identify that which of the following findings indicates fluid ov
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
erload?
A. Diminished bowel sounds
5z 5z 5z
B. Bradycardia
5z
C. Hypotension
5z
D. Bounding pulses - ANSWERS-D. Bounding pulses
5z 5z 5z 5z 5z 5z
,A nurse is caring for a client following an open colectomy. Which of the following fi
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
ndings places the client at risk for delayed wound healing?
5z 5z 5z 5z 5z 5z 5z 5z 5z
A. INR 1.1
5z 5z
B. Hyperemesis
5z
C. HbA1c 5.6%
5z 5z
D. Uncontrolled pain - ANSWERS-B. Hyperemesis
5z 5z 5z 5z 5z
A home health nurse is reviewing treatment goals with a client who has diabetes
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
mellitus. The nurse should evaluate which of the following laboratory tests to deter
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
mine effective long-term management of blood glucose levels?
5z 5z 5z 5z 5z 5z 5z
A. 3-hr oral glucose tolerance test
5z 5z 5z 5z 5z
B. HbA1c
5z
C. Fasting blood glucose test
5z 5z 5z 5z
D. Urinalysis for ketones - ANSWERS-B. HbA1c
5z 5z 5z 5z 5z 5z
A nurse is caring for a client who has neutropenia due to HIV. Which of the followi
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
ng precautions should the nurse take while caring for this client?
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
A. Wear an N95 respirator
5z 5z 5z 5z
B. Insert an indwelling urinary catheter to monitor urinary output
5z 5z 5z 5z 5z 5z 5z 5z 5z
C. Monitor the client's vital signs every 8 hr
5z 5z 5z 5z 5z 5z 5z 5z
D. Use a dedicated stethoscope - ANSWERS-D. Use a dedicated stethoscope
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
A nurse is caring for a client who reports difficulty falling asleep at night. Which of
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
the following actions should the nurse take?
5z 5z 5z 5z 5z 5z
A. Encourage the client to ambulate in the hallway 1 hr before bedtime
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
B. Tell the client to avoid drinking fluids 1 hr before bedtime
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
C. Schedule routine care tasks during hours when the client is awake
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
D. Advise the client to leave the television in the room on when trying to fall aslee
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
p - ANSWERS-
5z 5z
C. Schedule routine care tasks during hours when the client is awake
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
A nurse is planning care for a newborn who has hyperbilirubinemia and is to receiv
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
e phototherapy. Which of the following interventions should the nurse include?
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
A. Clothe the newborn in light cotton
5z 5z 5z 5z 5z 5z
B. Check the newborn's temperature every 8 hrs. (every 4)
5z 5z 5z 5z 5z 5z 5z 5z 5z
C. Administer 120 mL of water between feedings
5z 5z 5z 5z 5z 5z 5z
D. Place the newborn 45 cm from the light source - ANSWERS-
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
D. Place the newborn 45 cm from the light source
5z 5z 5z 5z 5z 5z 5z 5z 5z
A nurse is planning care for a client who has schizophrenia and is having difficulty
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
expressing their feelings. Which of the following referrals should the nurse make?
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
A. Art therapist
5z 5z
B. Speech-language pathologist
5z 5z
C. Social worker
5z 5z
D. Recreational therapist - ANSWERS-A. Art therapist
5z 5z 5z 5z 5z 5z
A nurse is caring for a client who has heart failure and has started taking a loop di
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
uretic. Which of the following findings indicates the client is experiencing an advers
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
e effect of the medication?
5z 5z 5z 5z
A. Decreased reflexes
5z 5z
, B. Weight gain of 1.4 kg
5z 5z 5z 5z 5z
C. Increased urinary output
5z 5z 5z
D. Jugular vein distention - ANSWERS-A. Decreased reflexes
5z 5z 5z 5z 5z 5z 5z
At the start of an evening shift on a cardiac unit, a licensed practical nurse brings t
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
he nurse a list of client reports. Which of the following client reports should the nur
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
se assess first?
5z 5z
A. Constipation
5z
B. Indigestion
5z
C. Swollen ankles
5z 5z
D. Urinary frequency - ANSWERS-B. Indigestion
5z 5z 5z 5z 5z
. A nurse is caring for a client who has just returned to the unit following a broncho
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
scopy. Which of the following actions by the assistive personnel requires the nurse
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5
zto intervene?
5z
A. Encourages the client to use the incentive spirometer
5z 5z 5z 5z 5z 5z 5z 5z
B. Elevates the head of the client's bed
5z 5z 5z 5z 5z 5z 5z
C. Offers oral fluids to the client
5z 5z 5z 5z 5z 5z
D. Checks the client's pulse oximetry - ANSWERS-C. Offers oral fluids to the client
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
. A nurse in a mental health facility is interviewing a newly admitted client. Which o
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
f the following actions should the nurse take when conducting the interview?
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
A. Insist the client use direct eye contact during the interview
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
B. Seat the client at least 3.7m from the nurse
5z 5z 5z 5z 5z 5z 5z 5z 5z
C. Position the client's chair between the nurse's chair and the door
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
D. Lean in slightly when speaking to the client - ANSWERS-
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
D. Lean in slightly when speaking to the client
5z 5z 5z 5z 5z 5z 5z 5z
A nurse on a medical unit has just received change-of-
5z 5z 5z 5z 5z 5z 5z 5z 5z
shift report. Which of the following clients should the nurse assess first?
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
A. A 68-year-
5z 5z
old client who had a myocardial infarction 2 days ago and reports chest pain 4 on
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
a scale of 0 to 10
5z 5z 5z 5z 5z
B. A 48-year-
5z 5z
old client who has AIDS, pneumocystis pneumonia, and a temperature of 38.3 C (
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
101F)
C. A 60-year-old client who has COPD, is receiving 2 L/
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
min O2 via a nasal cannula, and has an oxygen saturation of 89%
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
D. A 26-year-
5z 5z
old female client who has pelvic inflammatory disease and is unable to void -
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
ANSWERS-A 68-year-
5z 5z
old client who had a myocardial infarction 2 days ago and reports chest pain 4 on
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
a scale of 0 to 10
5z 5z 5z 5z 5z
A nurse is assessing a client prior to performing a blood draw. The nurse should id
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
entify that an allergy to which of the following food can indicate that the client has
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
an allergy to latex?
5z 5z 5z
A. Peanuts5z
B. Shellfish
5z
C. Avocados
5z
FORM A,B,C EXAM QUESTIONS
WITH DETAILED ANSWERS
A nurse is admitting a client who has antisocial personality disorder. Which of the f
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
ollowing client behaviors should the nurse identify as consistent with this disorder?
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
A. Compulsive attention to details
5z 5z 5z 5z
B. Avoids interacting with others
5z 5z 5z 5z
C. Uses others for personal gain
5z 5z 5z 5z 5z
D. Socially awkward in group situations - ANSWERS-
5z 5z 5z 5z 5z 5z 5z
C. Uses others for personal gain
5z 5z 5z 5z 5z
A nurse is interpreting the cardiac rhythm strip of a client who was admitted with s
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
yncope. Which of the following images indicates that the client has atrial fibrillation
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
? - ANSWERS-
5z 5z
A client who has a diagnosis of complete placenta previa is admitted to the labor a
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
nd delivery suite at 36 weeks gestation with contractions 5 min in frequency and 1
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
min in duration. Which of the following actions should the nurse take?
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
A. Rupture the amniotic sac
5z 5z 5z 5z
B. Medicate the client for pain
5z 5z 5z 5z 5z
C. Prepare the client for a cesarean section
5z 5z 5z 5z 5z 5z 5z
D. Perform a vaginal exam - ANSWERS-
5z 5z 5z 5z 5z 5z
C. Prepare the client for a cesarean section
5z 5z 5z 5z 5z 5z 5z
A charge nurse on a pediatric unit is making assignments for a float nurse from th
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
e medical unit. Which of the following clients is appropriate to assign to the float n
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
urse?
A. A 10-year-old client who has pneumonia and is receiving respiratory treatments
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
B. A 4-year-old client who has a Wilms tumor and is receiving chemotherapy
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
C. An 8-month-
5z 5z
old client who is scheduled for a surgical repair of a ventricular septal defect tomor
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
row
D. A 14-year-
5z 5z
old client who is scheduled for discharge today following placement of a Harrington
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
rod - ANSWERS-A. A 10-year-
5z 5z 5z 5z 5z
old client who has pneumonia and is receiving respiratory treatments
5z 5z 5z 5z 5z 5z 5z 5z 5z
A nurse notices smoke coming from a client's room and discovers a fire in the was
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
tebasket. After moving the client to safety, which of the following is the priority acti
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
on?
A. Notify the facility operator.
5z 5z 5z 5z
B. Close the fire doors on the unit.
5z 5z 5z 5z 5z 5z 5z
C. Turn off oxygen sources.
5z 5z 5z 5z
D. Put out the fire with the appropriate extinguisher. - ANSWERS-
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
A. Notify the facility operator.
5z 5z 5z 5z
,A nurse is assessing an infant who has water intoxication. Which of the following fi
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
ndings should the nurse expect?
5z 5z 5z 5z
A. Generalized edema
5z 5z
B. Elevated urine specific gravity
5z 5z 5z 5z
C. Thready pulse
5z 5z
D. Increased hematocrit - ANSWERS-A. Generalized edema
5z 5z 5z 5z 5z 5z
A nurse is discussing the z-
5z 5z 5z 5z 5z
track administration of hydroxyzine with a newly licensed nurse. Which of the follo
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
wing statements indicates the newly licensed nurse understands the purpose of th
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
e technique?
5z
A. This technique prevents injury to the sciatic nerve
5z 5z 5z 5z 5z 5z 5z 5z
B. This technique decreases the risk of subcutaneous infiltration
5z 5z 5z 5z 5z 5z 5z 5z
C. This technique allows a larger amount of medication to be injected
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
D. This technique increases the absorption rate of the drug - ANSWERS-
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
This technique decreases the risk of subcutaneous infiltration
5z 5z 5z 5z 5z 5z 5z
A nurse is creating a plan of care for a client who has anorexia nervosa. Which of
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
the following interventions should the nurse include in the plan?
5z 5z 5z 5z 5z 5z 5z 5z 5z
A. Encourage the client to gain 2.3 kg per week
5z 5z 5z 5z 5z 5z 5z 5z 5z
B. Weigh the client once per week throughout hospitalization
5z 5z 5z 5z 5z 5z 5z 5z
C. Monitor the client for 1 hr after meals
5z 5z 5z 5z 5z 5z 5z 5z
D. Allow the client to choose mealtimes - ANSWERS-
5z 5z 5z 5z 5z 5z 5z 5z
C. Monitor the client for 1 hr after meals
5z 5z 5z 5z 5z 5z 5z 5z
A nurse is planning care for a child who has increased intracranial pressure with a
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5
decrease in level of consciousness. Which of the following interventions should the
z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
nurse include in the plan of care?
5z 5z 5z 5z 5z 5z 5z
A. Perform active range-of-motion exercises
5z 5z 5z 5z
B. Maintain the head at a midline position
5z 5z 5z 5z 5z 5z 5z
C. Suction the airway frequently
5z 5z 5z 5z
D. Perform neurological checks every 4 hrs - ANSWERS-
5z 5z 5z 5z 5z 5z 5z 5z
B. Maintain the head at a midline position
5z 5z 5z 5z 5z 5z 5z
10. A nurse is assessing a client who has delirium due to a febrile illness. Which o
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
f the following findings should the nurse expect?
5z 5z 5z 5z 5z 5z 5z
A. Hallucinations
5z
B. Agnosia5z
C. Bradycardia
5z
D. Aphasia - ANSWERS-A. Hallucinations
5z 5z 5z 5z
A nurse is assessing a client who is receiving enteral feedings via a gastrostomy t
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
ube. The nurse should identify that which of the following findings indicates fluid ov
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
erload?
A. Diminished bowel sounds
5z 5z 5z
B. Bradycardia
5z
C. Hypotension
5z
D. Bounding pulses - ANSWERS-D. Bounding pulses
5z 5z 5z 5z 5z 5z
,A nurse is caring for a client following an open colectomy. Which of the following fi
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
ndings places the client at risk for delayed wound healing?
5z 5z 5z 5z 5z 5z 5z 5z 5z
A. INR 1.1
5z 5z
B. Hyperemesis
5z
C. HbA1c 5.6%
5z 5z
D. Uncontrolled pain - ANSWERS-B. Hyperemesis
5z 5z 5z 5z 5z
A home health nurse is reviewing treatment goals with a client who has diabetes
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
mellitus. The nurse should evaluate which of the following laboratory tests to deter
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
mine effective long-term management of blood glucose levels?
5z 5z 5z 5z 5z 5z 5z
A. 3-hr oral glucose tolerance test
5z 5z 5z 5z 5z
B. HbA1c
5z
C. Fasting blood glucose test
5z 5z 5z 5z
D. Urinalysis for ketones - ANSWERS-B. HbA1c
5z 5z 5z 5z 5z 5z
A nurse is caring for a client who has neutropenia due to HIV. Which of the followi
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
ng precautions should the nurse take while caring for this client?
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
A. Wear an N95 respirator
5z 5z 5z 5z
B. Insert an indwelling urinary catheter to monitor urinary output
5z 5z 5z 5z 5z 5z 5z 5z 5z
C. Monitor the client's vital signs every 8 hr
5z 5z 5z 5z 5z 5z 5z 5z
D. Use a dedicated stethoscope - ANSWERS-D. Use a dedicated stethoscope
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
A nurse is caring for a client who reports difficulty falling asleep at night. Which of
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
the following actions should the nurse take?
5z 5z 5z 5z 5z 5z
A. Encourage the client to ambulate in the hallway 1 hr before bedtime
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
B. Tell the client to avoid drinking fluids 1 hr before bedtime
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
C. Schedule routine care tasks during hours when the client is awake
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
D. Advise the client to leave the television in the room on when trying to fall aslee
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
p - ANSWERS-
5z 5z
C. Schedule routine care tasks during hours when the client is awake
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
A nurse is planning care for a newborn who has hyperbilirubinemia and is to receiv
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
e phototherapy. Which of the following interventions should the nurse include?
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
A. Clothe the newborn in light cotton
5z 5z 5z 5z 5z 5z
B. Check the newborn's temperature every 8 hrs. (every 4)
5z 5z 5z 5z 5z 5z 5z 5z 5z
C. Administer 120 mL of water between feedings
5z 5z 5z 5z 5z 5z 5z
D. Place the newborn 45 cm from the light source - ANSWERS-
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
D. Place the newborn 45 cm from the light source
5z 5z 5z 5z 5z 5z 5z 5z 5z
A nurse is planning care for a client who has schizophrenia and is having difficulty
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
expressing their feelings. Which of the following referrals should the nurse make?
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
A. Art therapist
5z 5z
B. Speech-language pathologist
5z 5z
C. Social worker
5z 5z
D. Recreational therapist - ANSWERS-A. Art therapist
5z 5z 5z 5z 5z 5z
A nurse is caring for a client who has heart failure and has started taking a loop di
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
uretic. Which of the following findings indicates the client is experiencing an advers
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
e effect of the medication?
5z 5z 5z 5z
A. Decreased reflexes
5z 5z
, B. Weight gain of 1.4 kg
5z 5z 5z 5z 5z
C. Increased urinary output
5z 5z 5z
D. Jugular vein distention - ANSWERS-A. Decreased reflexes
5z 5z 5z 5z 5z 5z 5z
At the start of an evening shift on a cardiac unit, a licensed practical nurse brings t
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
he nurse a list of client reports. Which of the following client reports should the nur
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
se assess first?
5z 5z
A. Constipation
5z
B. Indigestion
5z
C. Swollen ankles
5z 5z
D. Urinary frequency - ANSWERS-B. Indigestion
5z 5z 5z 5z 5z
. A nurse is caring for a client who has just returned to the unit following a broncho
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
scopy. Which of the following actions by the assistive personnel requires the nurse
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5
zto intervene?
5z
A. Encourages the client to use the incentive spirometer
5z 5z 5z 5z 5z 5z 5z 5z
B. Elevates the head of the client's bed
5z 5z 5z 5z 5z 5z 5z
C. Offers oral fluids to the client
5z 5z 5z 5z 5z 5z
D. Checks the client's pulse oximetry - ANSWERS-C. Offers oral fluids to the client
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
. A nurse in a mental health facility is interviewing a newly admitted client. Which o
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
f the following actions should the nurse take when conducting the interview?
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
A. Insist the client use direct eye contact during the interview
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
B. Seat the client at least 3.7m from the nurse
5z 5z 5z 5z 5z 5z 5z 5z 5z
C. Position the client's chair between the nurse's chair and the door
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
D. Lean in slightly when speaking to the client - ANSWERS-
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
D. Lean in slightly when speaking to the client
5z 5z 5z 5z 5z 5z 5z 5z
A nurse on a medical unit has just received change-of-
5z 5z 5z 5z 5z 5z 5z 5z 5z
shift report. Which of the following clients should the nurse assess first?
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
A. A 68-year-
5z 5z
old client who had a myocardial infarction 2 days ago and reports chest pain 4 on
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
a scale of 0 to 10
5z 5z 5z 5z 5z
B. A 48-year-
5z 5z
old client who has AIDS, pneumocystis pneumonia, and a temperature of 38.3 C (
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
101F)
C. A 60-year-old client who has COPD, is receiving 2 L/
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
min O2 via a nasal cannula, and has an oxygen saturation of 89%
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
D. A 26-year-
5z 5z
old female client who has pelvic inflammatory disease and is unable to void -
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
ANSWERS-A 68-year-
5z 5z
old client who had a myocardial infarction 2 days ago and reports chest pain 4 on
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
a scale of 0 to 10
5z 5z 5z 5z 5z
A nurse is assessing a client prior to performing a blood draw. The nurse should id
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
entify that an allergy to which of the following food can indicate that the client has
5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z 5z
an allergy to latex?
5z 5z 5z
A. Peanuts5z
B. Shellfish
5z
C. Avocados
5z
