Comprehensive Predictor ATI 1ST Retake 2025 With Complete Solution

1. A nurse is caring for a child with sickle cell anemia and is having a vaso-occlusive crisis. Which intervention should the nurse implement first? D) Increase oral fluid 2. A nurse is caring for a 1-day-old newborns who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take? Ensure that the newborn wears a diaper. 3. A nurse is preparing a client for a paracentesis. What action should the nurse take? Instruct the client to void prior to the procedure. 4. A nurse is providing dietary teaching to a client who has end-stage of kidney disease and a potassium level of 6. Which of the following is the best food the nurse to recommend? 1. Hard boiled eggs. 5. A director of nursing in a rehab facility is planning for measure of quality care provided. Which of the following should the nurse director plan to use after the client is discharged to gather information about quality of care? a. Outcome audit 6. A nurse is caring for a client who repeatedly refuses meals, a nurse overhears an AP telling the client “If you don’t eat, I’ll put restraint on you” … The nurse should intervene. a. Assault 7. A nurse is caring for a client who reports insomnia. Which of the following is a priority for the nurse to report to the provider? a. Wake up to urinate during the night. lOMoAR cPSD| 8. A nurse is planning care for a client who has an L4 spinal cord injury. Which of the following interventions to prevent skin breakdown should the nurse include in the plan of care? a. Massage reddened area over bony prominences 9. charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following should the nurse include in the teaching? 1. Applying elbow immobilizers of an infant receiving cleft lip injury 10. A nurse preparing to initiate IV fluid via infusion pump to a client. Which of the following action should the nurse take? a. Check the expiration date? 11. A nurse is proving discharge instruction about newborn to client who is 2 days postpartum. Which of the following should be include? a. Use car seat when travelling by airplane 12. A nurse as identified task to delegate to a group of an AP. a. Evaluate to perform each task b. Communicate appropriate task to AP 13. Adverse effect of furosemide? a. Hearing loss 14. New diagnose of type 2 diabetes. Client readiness to learn: a. I like to wait when my partner is here so we can both learn together. 15. Diazepam overdose medication for reversal? a. Flumazenil lOMoAR cPSD| 16. The nurse is planning a community health program about Parkinson’s disease. Which of the following intervention the nurse indicates as a tertiarily prevention strategy? a. Ambulation for client with Parkinson’s disease 17. A nurse is teaching a newly license nurse about incident report. Which of the following statement indicate understanding? a. They assist with quality improvement. 18. Peak expiratory flow meter teaching: Blow air as hard and quickly as possible. 19. A nurse is caring for an infant who has RSV. a. Suction prior to feeding. 20. A nurse is preparing to teach the parent of a child who has cystic fibrosis. Which of the following teaching should the nurse plan to include? a. Provide a diet high in protein and calories. 21. Taking Cyclosporine following a kidney transplant. Which Lab to report? a. Creatinine of 1.6 22. Auditory Hallucination teaching? a. Encourage the client listen to music. 23. A nurse is preforming a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following action should the nurse take? B. Insert a large-bore NG tube. 24. A nurse is planning care for a group of clients, which of the following measure should the nurse to manage time effectively? a. Gather supplies prior to completing a dressing change. lOMoAR cPSD| 25. A nurse is teaching a group of newly licensed nurses about client advocacy. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? a. “I will intervene if there is conflict between a client and his provider” 26. A nurse is assessing a client who is pregnant and has new diagnosis of hyperemesis gravidarum. Which of the following finding should the nurse expect? a. Urine output of 20 mL/Hr. 27. Apply physical restraint: a. to maintain the patency of an IV line 28. A nurse is assessing a client who has anorexia nervosa. Which of the following finding indicates effectiveness of the treatment plan? a. The client has clinical manifestation of dehydration 29. A nurse is assessing and older adult for social isolation. The nurse should identify that which of the following statement by the client indicates a risk for social isolation? a. My hearing aids have lost so I don’t attend Bingo like I used to. 30. A nurse is teaching a client who is pregnant and has a new prescription for Iron supplement. Which of the following statement should the nurse include? a. You might become constipated while taking this medication. 31. Abdominal Assessment orders: a. Inspection; Auscultation; Percussion; Palpation. 32. First indication of Peritonitis? a. Abdominal pain lOMoAR cPSD| 33. A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following action should the nurse take? a. Prepare client for intubation 34. A nurse is caring for a client who is 4 hours postpartum, client report urges to void but unable to void. Which of the following action should the nurse take? a. Massage the fundus 35. Screening an adolescent for idiopathic scoliosis, which of the following assessment should the nurse perform part of the screening? a. Measure the trunk location 36. Postpartum hemorrhage teaching? a. Inversion of the uterus. 37. A charge nurse is preparing to lead negotiations among nursing staff due to conflict about overtime requirements. Which of the following strategies should the nurse use to promote effective negotiation? a. Attempts to understand both sides of the situation. 38. Kosher diet tradition food choice? a. Scramble eggs and toast with milk. 39. A nurse is caring for client who is 11 weeks’ gestation, which of the following immunization should the nurse recommends? a. Inactivated Influenza vaccine b. Tetanus diphtheria and acellular pertussis vaccine. lOMoAR cPSD| 40. A home health nurse is preparing to make an initial visit to a family home from a local provider. Identify the sequence of the step the nurse should take when conducting a home visit. A. 3) Identify family needs interventions using the nursing process. B. 4) Record information about the home visit according to agency policy. C. 2) Contact the family to determine availability and readiness to make an appointment D. 5) Discuss plans for future visits with the family. E. 1) Clarify the reason for the referral with the provider’s office. E C A B D 41. A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. The nurse should identify that which of the following finding as sign of magnesium toxicity. a. Hyperventilation 42. Newborn that has been circumcised. Which of the following instruction should the nurse include in the teaching? a. Apply petroleum jelly at each diaper changes 43. Discharge teaching for client with type 1 diabetes about preventing diabetic-keto- acidosis: a. I should check my blood sugar twice a day 44. The nurse is caring for a client who is obese, the client is crying “everyone is staring at me because my weight”, which of the following is the proper response should the nurse make? a. Do you feel uncomfortable around others? 45. A nurse is teaching about preventative measures to a female client who has chronic urinary tract infections. Which of the following interventions should the nurse include in the teaching? a. Void every 4 hours. 46. A nurse is teaching a client who has heart failure about engaging in exercise program. Which of the following statement by the client indicates an understanding of teaching? a. Make sure you can still talk while exercising 47. Leave against medical advice: a. Ask the client to sign a form. 48. A nurse is assessing a client who has opioid use disorder. Which of the following should the nurse expect for opioid withdrawal? a. Tachycardia lOMoAR cPSD| 49. Client with COPD? a. Give the client autonomy and scheduling activity 50. Anti-embolic stocking: a. Make sure the client stockings are biding. 51. Pressure ulcer where Coccyx fat is visible is: a. Stage 3 52. Oxycodone? a. Avoid grapefruit juice 53. A nurse mangaer is reviewing documentation with a newly licensed nurse. Which of the following notations by the newly licensed nurse indicates an understanding of the teaching? a. “Administered 8 u regular insulin sq.” 54. Dressing change in a child? a. Explain in simple term how the procedure is going to affect the child. 55. Phenelzine what can you eat? a. Whole grain bread 56. 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? a. Apply fetal heart rate monitor 57. Teaching about security computerized? a. Information technology will install a firewall to protect client information. 58. Client advocacy a. …a client gets a second opinion for diagnosis. 59. A nurse is preparing discharge information for a client who has type 2 diabetes mellitus. Which of the following resources should the nurse provide to the client? a. Food exchange lists for meal planning from the American Diabetes Association 60. A nurse is caring for a client wo has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take? a. (Limit or remove?) IV bag from exposure to light. 61. The nurse is teaching a group of clients at a community health fair about genetic disease. Which of the following statements by a client indicates an understanding of the teaching? C. “My family has genetic risk for breast cancer, so I am considering a total mastectomy” lOMoAR cPSD| 62. National notifiable disease: a. Lyme disease. 63. Intracranial pressure following a brain injury? 64. Positive Skin TB test for a client: a. 10 65. A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for paternal fluid therapy. The guardian asks. “What are the indications that my baby needs an IV?” Which of the following responses should the nurse make? A. “Your baby needs an IV because she is not producing any tears” 66. Postpartum hemorrhage medication: a. Methylergonovine 67. A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan? . Place the client’s left arm on a pillow while he is sitting. 68. Child has been sexually abused by family member. a. Use leading statement to obtain information from the child. 69. A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first? a. Monitor vital signs. 70. Client partner recently died; the nurse stays with the client: a. Beneficent b. RN Comprehensive Predictor 2019 Form A 1.A nurse in a pediatric unit is preparing to insert an IV catheter for 7-year-old. Which of the following actions should the nurse take? 1. Tell the child they will feel discomfort during the catheter insertion. 2. A nurse is caring for a client who has arteriovenous fistula Which of the following findings should the nurse report? lOMoAR cPSD| Absence of a bruit. 3. A nurse is providing discharge teaching for a client who has an implantable cardioverter defibrillator which of the following statements demonstrates understanding of the teaching? 1. “I will wear loose clothing around my ICD” 4. A nurse is caring for a client who is at 14 weeks gestation and reports feelings of ambivalence about being pregnant. Which of the following responses should the nurse make? 1. “Describe your feelings to me about being pregnant” 5. 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? 1. Administer a rectal suppository 30 minutes prior to scheduled defecation times. 6. A nurse is caring for a client who is in active labor and requests pain management. Which of the following actions should the nurse take? 1. Place the client in a warm shower. 7. a nurse in an emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority? 1. Below-the knee amputation 8. a nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include? 1. Document the client’s condition every 15 min 9. A nurse is teaching an in-service about nursing leadership. Which of the following information should the nurse include about an effective leader? 1. Acts as an advocate for the nursing unit. 10. A nurse is reviewing the laboratory findings of a client who has diabetes mellitus and reports that she has been following her (unable to read) care. The nurse should identify which of the following findings indicates a need to revise the client’s plan of care. 1. Hba1c 10 % lOMoAR cPSD| 11. A nurse in a provider’s office is reviewing the laboratory results of a group of clients. The nurse should identify that which of the following sexually transmitted infections is a nationally notifiable infectious disease that should be reported to the state health department? 1. Chlamydia 12. A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. Which of the following group facilitation techniques should the nurse include in the teaching? 1. Use modeling to help the clients improve their interpersonal skills 13. A nurse is planning for a client who practices Orthodox Judaism. The client tells the nurse that (Unable to read) Passover holiday. Which of the following action should the nurse include in the plan of care? 1. Provide unleavened bread. 14. A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the effectiveness of the treatment 1. The client reports feeling less anxious. 15. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets (Unable to read) a respiratory rate of 10/min. After securing the client’s airway and initiating an IV, which of the following actions should the nurse do next. 1. Administer flumazenil to the client. 16. A nurse in an emergency department is caring for a client who reports cocaine use 1hr ago. Which of the following findings should the nurse expect? 1. Elevated temperature 17. A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl. Which of the following manifestations should the nurse expect? B. Jitteriness 18. A nurse in a pediatric clinic is reviewing the laboratory test results of a school age child. Which of the following findings should the nurse report to the provider? 1. WBC 14,000/mm3 lOMoAR cPSD| 19. A charge nurse is teaching a newly licensed nurse about clients designating a health care proxy in situations that require a durable power of attorney for heal care (DPSHC). Which of the following information should the charge nurse include? 1. “The proxy can make treatment decisions if the client is under anesthesia.” 20. A nurse in the PACU is caring for a client who reports nausea. Which of the following actions should the nurse take first? 1. Turn the client on their side. 21. A nurse is caring for a client who has a history of depression and is experiencing a situational crisis. Which of the following actions should the nurse take first? 1. Confirm the client’s perception of the event 22. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following should the actions should the nurse take? 1. Document the client’s condition every 15 minutes. 25. A nurse is working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan? 1. Place the client upright on a donut-shaped cushion 25. A nurse is caring for a client who is dilated to 10 cm and pushing. Which of the following pain-management (Unable to read) a safe option for the client? following is an appropriate nursing intervention? 1. Place the bedside table on the right side of the bed. 27. A nurse is assessing a client who has major depressive disorder. Which of the following findings should the nurse identify as the (Unable to read) (Most important?) 1. The client reports giving away personal items. 28. A nurse is providing teaching about immunizations to a client who is pregnant. The nurse should inform the client that she can receive which of the following immunizations during pregnancy? (Select all that apply) 1. Tetanus diphtheria and acellular pertussis vaccine lOMoAR cPSD| 2. Inactivated influenza vaccine. 29. 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 condition in the child’s medical history should the nurse identify as a contraindication to the procedure? C. Hypertension 31. A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make? 1. “I can give you information about respite care if you are interested.” 31. A nurse is assessing a child who is being treated for bacterial pneumonia. The nurse notes an increase in the child’s glucose. The nurse should identify this finding as an adverse effect of which of the following medications A. Methylprednisolone. 32. The nurse is providing teaching about folic acid to a client who is prima gravida. Which of the following information should the nurse include in the teaching? 1. “You can increase your dietary intake of folic acid by eating cereals and citrus fruits”. 33. A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse’s priority? A. Social relationship with peers. B. Plans for attending school while pregnant. C. (Unable to read) (Picked this one) Medicaid? D. Understanding of infant care. 34. A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse include? 1. decrease health care costs. 35. A nurse is reviewing the medical record of a client who has schizophrenia. Which of the following should the nurse report to the provider? Exhibit 1 Blood pressure: 102/56 mm Hg. Heart rate: 95/min Respiratory rate: 18/min Temperature: 37.4C (99.3F) lOMoAR cPSD| Exhibit 2 Medication Administration Record Clozapine 150 mg PO twice daily Benztropine 0.5 mg PO twice daily as needed for tremors. Exhibit 3 Nurse’s notes: Client reports feeling dizzy when changing positions, Reports weight gain of 1kg (2.2 lb.) in the past month. Also reports a sore throat for the past 3 days and dry mouth. Client ate 75% of breakfast and reports slightly nauseous. 1. Sore throat. 36. A charge nurse is educating a group of unit nurses about delegating client tasks to assistive personnel D. “An RN evaluates the client needs to determine tasks to delegate” 37. A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider? 1. FHR baseline 170/min 38. A nurse working in a rehabilitation facility is developing a discharge plan for a client who has left-sided hemiplegia the following actions is the nurse’s priority? 1. Ensure that the client has a referral for physical therapy. 39. A nurse in a mental health unit is planning room assignments for four clients. Which of the following client should be closest to the nurse’s station? 1. A client who has depressive disorder and reports feeling hopeless. 40. A nurse is preparing to measure a temperature of an infant. Which of the following action should the nurse take? 1. Place the tip of the thermometer under the center of the infant’s axilla. 41. 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? 1. Encourage the client to take frequent rest periods lOMoAR cPSD| 42. A nurse is admitting medications to a group of clients. Which of the following occurrences requires the completion of an incident report? 1. A client receives his antibiotics 2hr late 43. A nurse is caring for a client who is 24 hr. postpartum and is breast feeding her newborns. The client asks the nurse to warm up seaweed soup that the client’s partner brought for her. Which of the following responses should the nurse make? 1. “Does the doctor know you are eating that?” 44. 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? 1. Administering potassium via IV bolus 45. a nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching? 1. Establish a toileting schedule for the client 46. The nurse is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client’s history is a contradiction to the use of oral contraceptives? B. Thrombophlebitis. 47. A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations. The client states, “It’s hard not to listen to the voices.” Which of the following questions should the nurse ask the client? 1. “What helps you ignore what you are hearing?” 48. A charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following should the nurse include in the teaching? 2. Applying elbow immobilizers of an infant receiving cleft lip injury 49. A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.47, PaCo2 32 mm Hg. HCO3 22 mm Hg. The nurse should recognize that the Respiratory alkalosis 50. A nurse is preparing to mix NPH and regular insulin in the same syringe. Which of the following lOMoAR cPSD| 1. Inject air into the NPH insulin vial. 51. a Nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? 2. “We should establish our roles in the initial session.” 51.A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella rooster. Which of the following information should the nurse include? 1. Children who have varicella are contagious until vesicles are crusted. 52. A staff nurse is observing a newly licensed nurse suction a client’s tracheostomy. Which of the following requires intervention by the staff nurse? 1. Waits 2 minutes between suctions. 53. A nurse is teaching at a community health fair about electrical fire prevention. Which of the following information should the nurse include in the teaching? 1. Use three pronged grounded plugs. 54. A nurse is providing care for a group of clients. Which of the following client’s should the nurse identify as having the highest risk for developing a pressure injury? 1. A client who has a T-tube following an open cholecystectomy. 55. A nurse is teaching a client who has glaucoma and a new prescription for timolol eyedrops. Which of the following statements indicates an understanding of the teaching? 1. “I will place pressure on the corner of my eye after using he eye drops” 56. A nurse is providing teaching to a client who is 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? 1. Swelling of the face 57. A nurse is caring for a client who has a diagnosis of stage IV metastatic cancer. Which of the following responses should the nurse make? 1. “I can give you information about making end of life decisions”. 59. A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect? lOMoAR cPSD| 1. Heightened perceptual field 60. A nurse is reviewing the laboratory report of a client who has been having lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect? 2. Administer the medication. 61. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? 1. Eat a light snack before bedtime 62. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer? A. Pregabalin 63. A nurse is caring for a client following insertion of a chest tube 12 hr. ago. The (Unable to read) following actions should the nurse take? 1. Report continuous bubbling in the water seal chamber. 64. A nurse is caring for a client who is receiving morphine 4 mg via IV bolus every 4 hr. PRN. The nurse should monitor for which of the following adverse effects? 1. Urinary retention. 65. A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states “I don’t know what to do. Everything has been happening so quickly.” Which of the following by the nurse is therapeutic? A. “Can you talk about what happens with your partner at home?” 66. A nurse is providing dietary teaching to a guardian of a preschooler who has a new diagnosis of celiac disease. Which of the following statements by the guardian indicates an understanding of the teaching? 1. “I will put my child on a gluten-free diet”. 67. A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take? 1. Prime IV tubing with 0.9% sodium chloride. lOMoAR cPSD| 68. A nurse is admitting a client who has diabetic ketoacidosis. Which of the following types of continuous infusions should the nurse initiate? 1. 0.9% normal saline. 69. A nurse is teaching who has chronic pain about avoiding constipation from opioid medications. Which of the following should the nurse include in the teaching? 1. Increase exercise activity 70. A nurse is teaching about preventative measures to a female client who has chronic urinary tract infections. Which of the following interventions should the nurse include in the teaching? 1. “Drink 2 liters of warm water per day”. 71. 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? 1. A client who has a hip fracture and a new onset of tachypnea 72. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include? 1. Consume food high in bran fiber 73. A nurse is caring for a 1-day-old newborns who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take? 2. Ensure that the newborn wears a diaper. 74. a nurse is teaching a group of newly licensed nurses about client advocacy. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? 1. “I will intervene if there is conflict between a client and his provider” 75. A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take? 1. Evaluate the client’s ability to help with repositioning. 76. A nurse is orientation a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates and understanding of PSV? lOMoAR cPSD| B. “It allows preset pressure delivered during spontaneous ventilation.” 77. A nurse is caring for an infant who has coaction of the aorta. Which of the following should the nurse identify as an expected finding? A. Weak femoral pulses 78. a nurse is auscultating for crackles on a client who has pneumonia. Which of the following anterior chest wall locations should the nurse auscultate? 79. A nurse is assisting with the development of an informed document for participation in a research study. Which of the following information should the nurse include? 1. A statement that participants can leave the study at will. 80. A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include? 1. Excessive sweating lOMoAR cPSD| 81. A nurse is caring for a client who has a new temporary synchronous pacemaker. Which of the following should the nurse report to the provider? 1. The client develops hiccups. 82. A nurse is preparing discharge information for a client who has type 2 diabetes mellitus. Which of the following resources should the nurse provide to the client? 1. Food exchange lists for meal planning from the American Diabetes Association 82.A nurse is providing teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching? 1. “You should push the button before physical activity to allow maximum pain control.” 83. A nurse is caring for a client who has diabetes mellitus and is receiving long-acting insulin for blood glucose management. The nurse should anticipate administering which of the following types of insulin? 1. Glargine insulin. 84. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following should the toddler participate? 1. Playing with a large plastic truck. 85. A nurse is caring for a client who is receiving intermittent feedings via a feeding via a feeding pump and is experiencing dumping syndrome. Which of the following actions should the nurse take? 1. (Unable to read) rate of the client’s feedings. 86. A nurse in an emergency department is caring for a client who received a dose of penicillin and is now anxious, flushing, tachycardic and has difficulty swallowing. Which of the following actions is the nurse’s priority? 1. Administer oxygen 87. A nurse is caring for a client who has Raynaud’s disease. Which of the following actions should the nurse take? 1. Provide information about stress management. 88. A nurse is reviewing the medical history of a client who has angina. Which of the following findings in the client’s medical history should identify as a risk factor for angina? lOMoAR cPSD| 1. Hyperlipidemia. 89. 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? 1. Magnesium hydroxide 30 ml PO. 90. A nurse overhears two assistive personnel (AP) discussing care for a client while in the elevator. Which of the following actions should the nurse take? 1. Report the incident to the AP’s charge nurse. 91. A nurse is planning care for a client who is receiving hemodialysis. Which of the following actions should the nurse include in the plan of care? 1. Check the vascular access site for bleeding after dialysis. 92. A nurse in the emergency department is caring for a client who reports intimate partner violence. Which of the following interventions is the nurse’s priority? 1. Determine if the client has any injuries. 93. A nurse is caring for a client who is in active labor and note 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? 1. Maternal hypoglycemia 94. A nurse is assessing a school-age child who has a urinary tract infection. Which of the following findings should the nurse expect? 1. Enuresis. 95. 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? 1. A client who is 1 day postoperative following a vertebroplasty 97. A nurse is providing teaching to the parents of a newborn genetic screening. Which of the following statement should the nurse include in the teaching? 1. “This test should be performed after your baby is 24 hours old.” lOMoAR cPSD| 98. A nurse is providing discharge teaching to a client who is postoperative following a colon resection and has a new ascending colostomy. Which of the following statements by the client indicates an understanding of the teaching? 1. “I should avoid eating popcorn and fresh pineapple” 99. A nurse is admitting a client who had a stroke and exhibits facial drooping, drooling and hoarseness. Which of the following is the nurse’s priority? 1. Place the client on NPO status. 100. A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make? C. “Rise slowly when getting out of bed” 101. A nurse is planning a teaching session for a client who is postoperative following a colon resection. Which of the following actions should the nurse take first? C. Determine the client’s current pain level. 102. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary recommendations should the nurse make? C. Broiled skinless chicken breast with brown rice. 103. A nurse is caring for a client who asks for information regarding organ donation. Which of the following should the nurse make? C. “Your desire to be an organ donor must be documented in writing.” 104. A nurse is teaching a female client about personal hygiene. Which of the client actions indicates an understanding go the teaching? D. The client brushes her teeth twice daily. 107. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take? C. Auscultate the newborn’s apical pulse for 60 seconds. 108. A nurse is caring for a client who has pneumonia and has gained 4.2 kg (9.3 lb) over the last 5 days. The client’s laboratory values this morning are the following: WBC 10,000/mm3, RBC 5.2 million/mm3, platelets 250,000/mm3, BUN, and serum creatinine 2.1 mg/dL. The nurse should report these finding to which of the following members of the interdisciplinary team? lOMoAR cPSD| C. Nephrologist 109. A nurse is caring for an infant who is in contact isolation and received a blood transfusion. Which of the following actions is appropriate for the nurse to take to provide cost-effective care? A. Return unopened equipment to the supply center 108. A nurse is reviewing the medical record of a client who is postoperative following a total hip arthroplasty. For which of the following findings should the nurse contact the provider? D. WBC count 14,000 mm3 109. A nurse is preparing education material for a client. Which of the following techniques should the nurse use in creating material? A. Emphasize important information using bold lettering. 110. A nurse is creating for a client who has aids. The client states, “My mouth is sore when I eat.” Which of the following instructions should the nurse provide? B. “Ice chips” 111. 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? D. Contractions 112. 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? Apply fetal heart rate monitor. 113. A home health nurse is preparing to make an initial visit to a family following a referral from a local provider. Identify the sequence of steps the nurse should take when conducting a home visit. (Move the steps into the box on the right. Placing them in the order of performance) a. 3) Identify family needs interventions using the nursing process. b. 4) Record information about the home visit according to agency policy. c. 2) Contact the family to determine availability and readiness to make an appointment d. 5) Discuss plans for future visits with the family. e. 1) Clarify the reason for the referral with the provider’s office. E C A B D (My choice) 115. A nurse is caring for a client who is receiving intermittent eternal tube feeding. Which of the following places the client at risk for aspiration? lOMoAR cPSD| B. A History of gastroesophageal reflux disease 116. 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? C. Eat 1g/kg of protein per day 118. A nurse on a telemetry unit is assessing a client who is receiving continuous cardiac monitoring. The client’s heart rate is 69/min and the PR interval is 0.24 seconds. The nurse should interpret this finding as which of the following cardiac rhythms? A. First degree AV block 119. A nurse is supervising an assistive personnel (AP) who is feeding a client. The nurse observes that the client coughs after each bite. After asking the AP to stop feeding the client, which of the following actions should the nurse take next? 1. Listens to the client’s lung sounds. 120. A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan? A. Ask the client directly what he is hearing 120. The nurse is teaching a group of clients at a community health fair about genetic disease. Which of the following statements by a client indicates an understanding of the teaching? “My family has genetic risk for breast cancer, so I am considering a total mastectomy” 121. A nurse is planning discharge teaching about cord care for the parents of a newborn. Which of the following instructions should the nurse plan to include in the teaching? D. “Keep the cord stump dry until it falls off.” 122. A nurse is providing teaching to a client who is on glucocorticoid therapy. Which of the following statements by the client indicates an understanding of the teaching? B. “I take a calcium vitamin supplement daily” 123. A nurse is teaching a newly licensed nurse about ergonomic principles. Which of the following actions by a newly licensed nurse indicates an understanding of the teaching? C. Uses a mechanical lift to move client from bed to chair. lOMoAR cPSD| 124. A client is requesting information from a nurse about a nitrazine test. Which of the following statements should the nurse make? 2. “This test will determine if there is leaking amniotic fluid” 125. A Nurse is assessing a client who has hyponatremia and is receiving IV fluid therapy. Which of the following findings indicate the client is developing a complication of therapy? A. Peripheral edema 126. A nurse is conducting a home visit for a family who has two young children. The nurse notes several welts across the backs of the legs of one of the children. Which of the following actions should the nurse take first? B. Contact child protective services. 127. A nurse is planning care for a client who has thrombocytopenia. Which of the following actions should the nurse include? Provide the client what a stool softener. 128. 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 131. A nurse is caring for a client who has left-sided heart failure, and the provider is concerned that the client might develop (Unable to read) Which of the following actions should the nurse take? Place the client in high fowler’s position. 132. A charge nurse is teaching a newly licensed nurse about the administration of total parenteral nutrition. Which of the following should the charge nurse include? A. “You will need to monitor the client’s electrolytes daily” 133. A nurse is teaching a prenatal class about infection at a community center. Which of the following statements by a client indicates an understanding of the teaching? A. “I can visit my nephew who has chickenpox 5 days after the sores have crusted.” 133. A nurse is caring for a client who has end-stage liver cancer. Which of the following statements should the nurse make to support the client’s right to autonomy?