ATI RN EXIT Exam Questions & Answers Latest Update 2023 Graded A

ATI RN EXIT Exam Questions & Answers Latest Update 2023 Graded A 1. A nurse is assessing a newborn who has patent ductus arteriosus. Which of the following findings should the nurse except? D. Bounding pulse 2. A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? a. Measure the client’s urine output every hour. - monitor for toxicity. . 3.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 her father. Which of the following conditions in the child’s medical history should the nurse identify as a contraindication to the procedure? a. Hypertension 4.A nurse is caring for a client who has COPD and is 5kg (11lb) below her ideal body weight. The client experiences shortness of breath when eating. Which of the following actions should the nurse take? b. Request non gas forming foods from the dietary department 5. A nurse is reviewing the laboratory findings of a client who is receiving IV infusion of insulin. The client’s lab findings reveal a potassium level of 5.5 mEq/L, BUN of 15 mg/dL, and a creatinine level of 1 mg/dL. Which of the following interventions is appropriate for the nurse to take? . 6.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? c. I can resume activities, such as sewing. 7. A nurse is planning to administer vancomycin IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin? a. Give the dose over 60 min 8.A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching ? b. Eat 1g/kg of protein per day 9.A nurse is delegating tasks to an assistive personnel group of clients. Which of the following statements should the nurse make? c. Tell me the standing weight of the client in room 102 before breakfast 10. A nurse is caring for a client who has heart failure and is receiving a continuous IV infusion of low dose dopamine. Which of the following findings is the highest priority? a. Erythema 5 cm (2in) above the IV site 11.A nurse is providing teaching about the use of crutches using a three-point gait to a client who has tibia fracture. Which of the following actions by the client indicates an understanding of the teaching? A. Positioning both hands on the grips with his elbows slightly flexed 12. A nurse is assessing a 24-month-old toddler during a well-child visit. Which of the following developmental tasks should the toddler be able to perform? B. Kick a ball forward 13. 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? D. We can review some information to help you select a safe alternative practitioner. 14. A nurse is assessing a client following a ischemic stroke. Which of the following findings is the priority for the nurse to report to the provider? C. The client coughs after swallowing 15. 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 effectiveness of the procedure? A. Compare the client's current weight with preprocedure weight. 16. 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? C. Minimize noise in the newborn environment 17. A newly licensed nurse is reviewing the role of a nurse in disaster planning. Which of the following is an activity a nurse should engage in to assist in disaster preparedness? A. Participate in community drills and mock events. 18. A nurse is completing an admission assess for a client who has narcissistic personality C. Preoccupied with aging 19. A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan? C. Encourage the client to take frequent rest periods 20. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary recommendations should the nurse make? C. B roiled skinless chicken breast with brown rice. 21. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take? A. Obtain the newborn’s body temperature using a tympanic thermometer. 22. A nurse is caring for a client who is at 38 weeks gestation, is in active labor, and has ruptured membrane. Which of the following actions should the nurse take? B . Apply fetal heart rate monitor. 23. A nurse is assessing a client who is 30 min postoperative following an arterial thrombectomy. Which of the following findings should the nurse to report? A. . Chest pain 24. A nurse is completing an incident report after a client fall. Which of the following competencies of Quality and Safety Education for Nurse is the use demonstrating? Quality improvement. 25. A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of the following actions should the nurse take? D. N otify the nursing manager about the suspected alcohol use. 26. A nurse is caring for a client who has diaper dermatitis. Which of the following actions should the nurse take? A . Apply zinc oxide ointment to the irritated area. 26. A nurse is reviewing the facility’s safety protocols considering newborn abduction with the parent of a newborn. Which of the following statements indicates an understanding of the teaching? B. “I will not publish public announcement about my baby’s birth” 27. A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record? B. “ Morphine 3 mg Subcutaneous (Unable to read) 28. A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first? C. M onitor vital signs. 29. A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make? B. “ Dehydration can increase the risk of preterm labor” 30. A nurse is receiving a change-of-shift report for an adult female client who is postoperative. Which of the following client information should the nurse report? C. A nswer might be lower platelets. 31. A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. Which of the following instructions should the nurse include? B. ( Answer was the nurse was going to do the interpretation) 32. A cardinal symptom of the schizophrenic client is hallucinations. A nurse identifies this as a problem in the category of: B. Sensory-perceptual alterations 33. Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional alterations; delusional thinking; negative view of self; and feelings of abandonment. These clinical features of the client’s depression alert the nurse to prioritize problems and care by addressing which of the following problems first: C. Possible harm to self 34 . A patient is admitted to the same day surgery unit for liver biopsy. Which of the following laboratorytests assesses coagulation? Select all that apply. Partial thromboplastin time. Prothrombin time. Platelet count. 35. The nurse is teaching the client how to use a metered dose inhaler (MDI) to administer a Corticosteroid drug. Which of the following client actions indicates that he is using the MDI correctly? Select all that apply. The inhaler is held upright. Mouth is rinsed with water following administration 36. The nurse is teaching a client with polycythemia vera about potential complications from this disease.Which manifestations would the nurse include in the client’s teaching plan? Select all that apply. Visual disturbance Headache Orthopnea Gout 37. Which of the following would be priority assessment data to gather from a client who has been diagnosedwith pneumonia? Select all that apply. Auscultation of breath sounds Presence of chest pain. Color of nail beds 38. The nurse is teaching a client who has been diagnosed with TB how to avoid spreading the disease tofamily members. Which statement(s) by the client indicate(s) that he has understood the nurses instructions? Select all that apply. “I should always cover my mouth and nose when sneezing.” “I should use paper tissues to cough in and dispose of them properly.” “I can use regular plate and utensils whenever I eat.” 39. The nurse is admitting a client with hypoglycemia. Identify the signs and symptoms the nurse shouldexpect. Select all that apply. Palpitations Diaphoresis Slurred speech 40. Which adaptations should the nurse caring for a client with diabetic ketoacidosis expect the client toexhibit? Select all that apply: Low PCO2 Acetone breath 41. When planning care for a client with ulcerative colitis who is experiencing symptoms, which client careactivities can the nurse appropriately delegate to a unlicensed assistant? Select all that apply. Providing skin care following bowel movements Maintaining intake and output records Obtaining the client’s weight. 42. Which of the following nursing diagnoses would be appropriate for a client with heart failure? Select allthat apply. Ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased cardiac output. Decreased cardiac output related to structural and functional changes. 43. When caring for a client with a central venous line, which of the following nursing actions should beimplemented in the plan of care for chemotherapy administration? Select all that apply. Verify patency of the line by the presence of a blood return at regular intervals. Inspect the insertion site for swelling, erythema, or drainage. If unable to aspirate blood, reposition the client and encourage the client to cough. Contact the health care provider about verifying placement if the status is questionable. 44. When assessing a client diagnosed with impulse control disorder, the nurse observes violent, aggressive, and assaultive behavior. Which of the following assessment data is the nurse also likely to find?Select all that apply. The client functions well in other areas of hislife. The degree of aggressiveness is out of proportion to the stressor. The client has a history of parental alcoholism and chaotic, abusive family life. 45. Which of the following nursing interventions are written correctly? (Select all that apply.) Elevate head of bed 30 degrees before meals. 46. The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client’s outflow isless than the inflow. Select actions that the nurse should take. Place the client in good body alignment Check the level of the drainage bag Check the peritoneal dialysis system for kinks Reposition the client to his or herside. 47. The nurse is caring for a hospitalized client who has chronic renal failure. Which of the following nursingdiagnoses are most appropriate for this client? Select all that apply. Excess Fluid Volume Imbalanced Nutrition; Less than Body Requirements Activity Intolerance 48. The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptomswould the nurse expect the child to demonstrate? Select all that apply. Head tilt Vomiting Lethargy 49. The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notesflushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply. Elevate the HOB to 90 degrees Loosen constrictive clothing Assess for bladder distention and bowel impaction Administer antihypertensive medication 50. The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the following statements indicates that the client has correctly understood the teaching? Select all that apply. “I can usually keepmy ostomy pouch on for 3 to 7 days before changing it.” “I must use a skin barrier to protect my skin from urine.” 51. A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and ischecking the client for probable signs of pregnancy. Select all probable signs of pregnancy. Uterine enlargement Chadwick’ssign Braxton Hicks contractions Ballottement 52. A nurse is monitoring a pregnant client with pregnancy induced hypertension who is at risk for Preeclampsia. The nurse checks the client for which specific signs of Preeclampsia (select all that apply)? Elevated blood pressure Facial edema 53. A 45-year-old client diagnosed with major depression is scheduled for electroconvulsive therapy (ECT) in the morning. Which of the following medications are routinely administered either before or during ECT? B. Atropine, sodium brevitol, and succinylcholine chloride (Anectine) 54. A 35-year-old client is receiving psychopharmacological treatment of his major depression with tranylcypromine sulfate (Parnate), a monoamine oxidase (MAO) inhibitor. The nurse teaches the client that while he is taking this type of antidepressant, he needs to restrict his dietary intake of: C. Tyramine 55. A 23-year-old female client is brought to the emergency room by her roommate for repeatedly making superficial cuts on her wrists and experiencing wide mood swings. She is very angry and hostile. Her medical diagnosis is adjustment disorder versus borderline personality disorder. The client comments to the nurse, "Nobody in here seems to really care about the clients. I thought nurses cared about people!" The client is exhibiting the ego defense mechanism: C. Splitting 56.A client hospitalized with a medical diagnosis of adjustment disorder versus personality disorder states, "Nobody cares about the clients." The nurse’s most effective response would be: D. "You seem angry. Tell me more about how you feel." 57.A measurable outcome criterion in the nursing care of an adolescent with anorexia nervosa would be: B. Verbalizing realistic feelings about her body 58. A 14-year-old teenager is hospitalized for anorexia nervosa. She is admitted to the adolescent mental health unit and placed on a behavior modification program. Nursing interventions for the teenager will most likely include: A. Establishing routine tasks and activities around mealtimes 59. One afternoon 3 weeks into his alcohol treatment program, a client says to the nurse, "It’s really not all my fault that I have a drinking problem. Alcoholism runs in my family. Both my grandfather and father were heavy drinkers." The nurse’s best response would be: B. "Risk factors can often be controlled by self-responsibility." 60. When preparing insulin for IV administration, the nurse identifies which kind of insulin to use? C. Regular 61. A 33-year-old client is diagnosed with bipolar disorder, acute phase. This is her first psychiatric hospitalization, and she is being evaluated for treatment with lithium. Which of the following diagnostic tests are essential prior to the initiation of lithium therapy with this client? B. Blood urea nitrogen, electrolytes, and creatinine 62. A client has been taking lithium 300 mg po bid for the past two weeks. This morning her lithium level was 1 mEq/L. The nurse should: C. Administer the morning lithium dose as scheduled 63. A 23-year-old male client is admitted to the chemical dependency unit with a medical diagnosis of alcoholism. He reports that the last time he drank was 3 days ago, and that now he is starting to "feel kind of shaky." Based on the information given above, nursing care goals for this client will initially focus on: D. Physiological stabilization 64. A 14-year-old boy has had diabetes for 7 years. He takes 30 U of NPH insulin and 10 U of regular insulin every morning at 7 AM. He eats breakfast at 7:30 AM and lunch at noon. What time should he expect the greatest risk for hypoglycemia? C. 11 AM 65. A 16-year-old diabetic girl has been selected as a cheerleader at her school. She asks the nurse whether she should increase her insulin when she is planning to attend cheerleading practice sessions lasting from 8 to 11 AM. The most appropriate answer would be: D. "No, do not increase your insulin, but eating a snack prior to practice exercise will make insulin more effective and move more glucose into the cells." 66. The physician decides to prescribe both a short-acting insulin and an intermediate-acting insulin for a newly diagnosed 8-year-old diabetic client. An example of a short-acting insulin is: A. Novolin Regular 67. Diabetes mellitus is a disorder that affects 3.1 out of every 1000 children younger than 20 years old. It is characterized by an absence of, or marked decrease in, circulating insulin. When teaching a newly diagnosed diabetes client, the nurse includes information on the functions of insulin: A. Transport of glucose into body cells and storage of glycogen in the liver 68. Cystic fibrosis is transmitted as an autosomal recessive trait. This means that: D. Both parents must be carriers for a child to have the disease 69. A 9-year-old child was in the garage with his father, who was repairing a lawnmower. Some gasoline ignited and caused an explosion. His father was killed, and the child has split-thickness and full-thickness burns over 40% of his upper body, face, neck, and arms. All of the following nursing diagnoses are included on his care plan. Which of these nursing diagnoses should have top priority during the first 2448 hours postburn? D. Potential for impaired gas exchange related to edema of respiratory tract 70. A female baby was born with talipes equinovarus. Her mother has requested that the nurse assigned to the baby come to her room to discuss the baby’s condition. The nurse knows that the pediatrician has discussed the baby’s condition with her mother and that an orthopedist has been consulted but has not yet seen the baby. What should the nurse do first? B. Question the mother and find out what the pediatrician has told her about the baby’s condition. 71. A child has a nursing diagnosis of fluid volume excess related to compromised regulatory mechanisms. Which of the following nursing interventions is the most accurate measure to include in his care? A. Weigh the child twice daily on the same scale. 72. The pediatric nurse charts that the parents of a 4-yearold child are very anxious. Which observation would indicate to the nurse unhealthy coping by these parents: D. Refusing to participate in the child’s care 73. A 9-week-old female infant has a diagnosis of bilateral cleft lip and cleft palate. She has been admitted to the pediatric unit after surgical repair of the cleft lip. Which of the following nursing interventions would be appropriate during the first 24 hours? B. Maintain elbow restraints in place unless she is being directly supervised. 74. A 6-month-old infant who was diagnosed at 4 weeks of age with a ventricular septal defect, was admitted today with a diagnosis of failure to thrive. His mother stated that he had not been eating well for the past month. A cardiac catheterization reveals congestive heart failure. All of the following nursing diagnoses are appropriate. Which nursing diagnosis should have priority? D. Decreased cardiac output related to ineffective pumping action of the heart 75. To assist an adult client to sleep better the nurse recommends which of the following? (Select all thatapply.) Consuming a small glass of warm milk at bedtime 76. A female client at 36 weeks' gestation has been treated successfully for premature labor for 4 weeks. She has begun having uterine contractions today and has been admitted to the labor and delivery suite. Her amniocentesis results reveal a lecithin/sphingomyelin (L/S) ratio of 2 and positive phosphatidylglycerol (PG). These lab values indicate: Fetal lung maturity 77. A primigravida with a blood type a negative is at 28 weeks' gestation. Today her physician has ordered a RhoGAM injection. Which statement by the client demonstrates that more teaching is needed related to this therapy? "I'm getting this shot so that my baby won't develop antibodies against my blood, right?" 78. at her monthly prenatal visit, a client reports experiencing heartburn. Which nursing measure should be included in her plan of care to help alleviate it? Eat small, frequent bland meals. 79. A client is dilated 8 cm and entering the transition phase of labor. Common behaviors of the laboring woman during transition are: Frustration, vague in communication 80. The FHR pattern in a laboring client beginsto show early decelerations. The nurse would best respond by: Continuing to monitor the FHR closely 81. A female client is admitted to the emergency department complaining of severe right-sided abdominal pain and vaginal spotting. She states that her last menstrual period was about 2 months ago. A positive pregnancy test result and ultrasonography confirm an ectopic pregnancy. The nurse could best explain to the client that her condition is caused by: A distended or ruptured fallopian tube 82. A female client at 10 weeks' gestation complains to her physician ofslight vaginal bleeding and mild cramps. On examination, her physician determines that A threatened abortion An incomplete abortion 83. A female client at 36 weeks' gestation is experiencing preterm labor. Her physician has prescribed two doses of betamethasone 12 mg IM q24h. The nurse explains that she is receiving this drug to: Promote fetal lung maturation 84. A client has returned to the unit following a left femoral popliteal bypass graft. Six hourslater, his dorsalis pedis pulse cannot be palpated, and his foot is cool and dusky. The nurse should: Notify the physician immediately 85. A client isto have a coronary artery bypass graft performed in the morning using a saphenous vein. He wants to know why the physician does not use the internal mammary artery for his bypass graft because his friend's physician uses this artery. The nurse tells the client that the internal mammary artery: Takes more time to remove 86. A client returnsto the cardiovascular intensive care unit following his coronary artery bypass graft. In planning his care, the most important electrolyte the nurse needs to monitor will be: Potassium 87. A client is being discharged from the hospital today. The discharge teaching for care of her colostomy included which of the following basic principles for protecting the skin around her stoma: Using a skin sealant under pouch adhesives 88. A client is being discharged from the hospital tomorrow following a colon resection with a left colostomy. The nurse knows that the client understands the discharge teaching about care of her colostomy when she says: 89. A client had a right below-the-knee amputation 4 days ago. He is complaining of pain in his right lower leg. The nurse should: Give the client his order of Demerol 50 mg IM prn 90. A client hasreturned to the unit from the recovery room after having a thyroidectomy. The nurse knowsthat a major complication after a thyroidectomy is: Respiratory obstruction 91. A client had a transurethralresection of the prostate yesterday. He is concerned about the small amount of blood that is still in his urine. The nurse explains that the blood in his urine: Is normal and he need not be concerned about it 92. A 72-year-old male client had the Foley catheter that was inserted during the transurethral resection of his prostate removed today. He is concerned about the urinary incontinence he is having since removal of the Foley catheter. The nurse explains that: Thisis usually temporary 93. A 48-year-old female client is going to have a cholecystectomy in the morning. In planning for her postoperative care, the nurse is aware that a priority nursing diagnosis for her will be high risk for: Ineffective breathing pattern 94. A client is having a pneumonectomy done today, and the nurse is planning her postoperative care. Nursing interventions for a postoperative left pneumonectomy would include: Monitoring the right lung for an increase in rales 95. A client returned to the unit following a pneumonectomy. As the nurse is assessing her incision, she notices fresh blood on the dressing. The nurse should first: Notify the physician. 96. A client had a renal transplant 3 months ago. He has suddenly developed graft tenderness, an increased white blood cell count, and malaise. The client is experiencing which type of rejection? Acute 97. A client has received preoperative teaching for the vertical partial laryngectomy that he is scheduled to have in the morning. The nurse determines that the teaching has been effective when the client states: "I will have very little difficulty swallowing after surgery." 98. A client being discharged from the hospital is beginning medication therapy with bumetanide (Bumex). The nurse instructs the client to contact the prescriber if which of the following contraindications for use develops while using this medication? Absence of urine output 99. The nurse should review the results of which of the following to evaluate a client's response to a lipid‐ lowering agent Liver function tests 100. A client taking cholestyramine (Questran) to lower lipid levels should be monitored for possible deficiency of which vitamin(s)? Vitamins A and D 101. After beginning an antihypertensive medication, the client returns for a follow‐up visit and complains of a dry, nonproductive cough. The nurse knows that this side effect is mostly caused by which type of antihypertensive medication? Angiotensin‐converting enzyme (ACE) inhibitor 102. A 28-year-old client performs a long, involved ritual in getting up and preparing for the day. He became unable to get to his job before noon. His family, in desperation, has admitted him to the hospital’s psychiatric unit. On the unit, he is always late for breakfast, which is served at 8 am. The nurse identifiesthat the best approach to this problem is to: Get him up early so that he can complete the ritual before breakfast 103. A client is diagnosed with Mycobacterium tuberculosis. He is placed in respiratory isolation, intubated,and receives mechanical ventilation. When performing suctioning, the nurse should: Hyperoxygenate before and after suctioning 104. A 67-year-old postoperative TURP client has hematuria. The nurse caring for him reviews his postoperative orders and recognizes that which one of thefollowing prescribed medications would best relieve this problem? Aminocaproic acid (Amicar) 6 g/24 hr 105. Before completing a nursing diagnosis, the nurse must first: Perform an assessment 106. . A client with a diagnosis of Methicillin resistant Staphylococcus aureus(MRSA) Has died. Which type of precautions is the appropriate type to use when performing postmortem care? C) contact precautions 107. The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is appropriate teaching? B) clean the meatus, begin voiding, then catch urine stream 108. The provider orders Lanoxin (digoxin) 0.125 mg POand furosomide 40mg Every day. Which of these foods would the nurse reinforce for the client to eat atleast daily? B) watermelon 109. A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse take? C) Immediately wash the hands with vigor 110. As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do? D) Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.” The 111. A client with Guillain Barre is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition? B) Glascow Coma Scale 8, respirations regular 112. A client enters the emergency department unconscious via ambulance from the client’s work place. What document should be given priority to guide the direction of care for this client? C) A notarized original of advance directives brought in by the partner 113. The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager? A) An admission at the change of shifts with atrial fibrillation and heart failure 114. A mother brings her 3 month-old into the clinic, complaining that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment? B) Restlessness and increased mucus production 115. As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis? C) "Clothes are becoming tighter across her abdomen." 116. A 16 year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse? D) Proceed with the triage process in the same manner as any adult client 117. A newly admitted elderly client is severely dehydrated. When planning care for This client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)? B) Report hourly outputs of less than 30 ml/hr 118. The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with thisdisease? B) Strep throat went through all the children at the day care last month. 119. A nurse assigned to a manipulative client for 5 days becomes awareof feelings for a reluctance to interact with the client. The next action by the nurse shouldbe to A) Discuss the feeling of reluctance with an objective peer or supervisor 120. A client is being treated for paranoid schizophrenia. When the clientbecame loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse’s action A) May result in charges of unlawful seclusion and restraint 121. A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority? A) Pain related to ischemia 122. The provisions of the law for the Americans with Disabilities Act require Nurse managers to B) Provide reasonable accommodations for disabled individuals 123. A 42 year-old male client refuses to take propranolol hydrochloride (Inderal) as prescribed. Which client statement s from the assessment data is likely to explain his noncompliance? C) "I have diminished sexual function." 124. A school-aged child has had a long leg (hip to ankle)synthetic castapplied 4 hours ago. Which statement from the mother indicates that teaching has been inadequate? D) ”I think I remember that standing cannot be done until after 72 hours." The 125. Which statement best describes time management strategies appliedto the role of a nurse manager? C) Set daily goals with a prioritization of the work 126. The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that is associated withthis problem include which of these? D) Abdominal mass and weakness 127. A 15 year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching? A) "I will only have to wear this for 6 months." 128. The nurse manager has been using a decentralized block schedulingplan to staff thenursing unit. However, staff have asked for many changes and exceptionsto the schedule over the past few months. The manager considers self schedulingknowing that this method will D) Improve team morale 129. uphenazine (Prolixin). Which should be a focus of the first assessment? B) Medication compliance 130. The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which intervention should take priority in planning care? B) Place client on a pressure reducing support surface 131. A nurse is conducting a community wide seminar on childhood safety issues. Which of these children is at the highest risk for poisoning? B) 20 month-old who has just learned to climb stairs 132. During an examination of a 2 year-old child with a tentative diagnosis of Wilm's tumor, the nurse would be most concerned about which statement by the mother? C) All the pants have become tight around the waist. 133. What is the most important aspect to include when developing a home care plan for a client with severe arthritis? A) Maintaining and preserving function 134. A mother asks the nurse if she should be concerned about the tendency of her child to stutter. What assessment data will be most useful in counseling the parent? A) Age of the child 135. A pre-term newborn is to be fed breast milk through nasogastric tube. Why is breast milk preferred over formula for premature infants? C) Provides antibodies 136. Which of the following nursing assessments in an infant is most valuable in identifying serious visual defects? A) Red reflex test 137. A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4cm by 7cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for this wound? D) Occlusive moist dressing 138. A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child? B) Large wooden puzzle 139. A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief, the nurse would explain that illness is attributed to the B) Yin, the negative force that represents darkness, cold, and emptiness 140. A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse "What is our major concern now, and what will we have to deal with in the future?" Which of the following is the best response? C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis." 141. Which type of accidental poisoning would the nurse expect to occur in children under age 6? A) Oral ingestion 142. A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly bothers other clients, tries to help the housekeeping staff, demonstrates pressured speech and demands constant attention from the staff. Which activity would be best for the client? D) Ping-pong 143. The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate? C) Distended neck veins 144. Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis? D) Note patterns of increased blood pressure 145. The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate? C) Confine the percussion to the rib cage area 146. A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating regular dinners. The client has also started frequenting bars to "see old buddies." The nurse understands that the client’s behavior is a warning sign to indicate that the client may be A) headed for relapse 147. A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to feeling sad and hopeless, the nurse would assess for C) Psychomotor retardation or agitation 148. A client is experiencing hallucinations that are markedly increased at night. The client is very frightened by the hallucinations. The client’s partner asked to stay a few hours beyond the visiting time, in the client’s private room. What would be the best response by the nurse demonstrating emotional support for the client? C) "Yes, staying with the client and orienting her to her surroundings may decrease her anxiety." 149. At a well baby clinic the nurse is assigned to assess an 8 month-old child. Which of these developmental achievements would the nurse anticipate that the child would be able to perform? C) Sit without support 150. The nurse is talking to parents about nutrition in school aged children. Which of the following is the most common nutritional disorder in this age group? C) Obesity 151. An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to A) administer the medication in 2 separate injections 152. The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to D) prevent the drug from tissue irritation Skip 153. A client with cervical cancer who is undergoing chemotherapy with cisplatin (Platinol). For which adverse effect of cisplatin will the nurse assess the client? C. Hearing loss 154. A nurse is monitoring a pregnant client with suspected partial placenta previa who is experiencing vaginal bleeding. Which of the following findings would the nurse expect to note on assessment of the client? D. Soft, relaxed, nontender uterus 155. A community health nurse is planning primary prevention activities to reduce the occurrence of abuse. Which of the following strategies should the nurse include in the plan? Teach parenting skills to families at risk for abuse 156. A nurse and an assistive personnel (AP) are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the AP? Applying a condom catheter for a client who has a spinal cord injury 157. A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching? “I will avoid food and beverages that contain caffeine” 158. 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? Provide humidification of the room air 159. A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel? b. Perform chest compressions during cardiac resuscitation 160. A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication for using lavender? c. The client has a history of asthma