VATI RN Comprehensive Predictor

lOMoAR cPSD| VATI RN Comprehensive Predictor 1. A community health nurse is evaluating eligibility for home assistance for a client who is quadriplegic. Which of the following actions should the nurse perform first? a. Determine the client's living situation. b. Problem solved with the client. c. Offer community resources to the client. d. Assist the client with decision-making. 2. A nurse is discussing care with a newly licensed nurse for a client who practices Orthodox Judaism. Which of the following meals suggestions by the newly licensed nurse indicates a need for further teaching? a. Chicken breast and boiled potatoes. b. Carrot sticks and cottage cheese. c. Grilled cheese an Apple sauce. d. Roast beef and ice cream. 3. A nurse is preparing to auscultate a client apical pulse at the point of maximal impulse (PMI). the nurse should place the diaphragm of the stethoscope at which of the following locations a. Within the angle of Louis. b. 5th intercostal space at the left midclavicular line. c. Second intercostal space to the right of the sternum. d. Over the xyphoid process. 4. A nurse is caring for a client who is receiving a blood transfusion at 125 mL/hour and develops a hemolytic reaction. Which of the following actions should the nurse perform? a. Infuse 0.9% sodium chloride IV. b. Administer an anti-pyretic. c. Decrease the infusion rate to 75 mL/hour. d. Place the client in a left lateral position 5. A nurse is planning care for a client who is prescribed a cane for ambulation. Which of the following nursing actions should the nurse include in the plan of care? a. Remind the client to place the cane on the unaffected side. b. Adjust the length of the cane to equal the distance from the client's iliac crest to the floor. c. Remove the rubber tip from the cane to enhance ambulation. d. Place the King safely in the closet during naps and at bedtime. 6. Nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65 mL/hour through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse? a. The gastric residual volume is 250 mL following two hours of infusion. b. The client is lying in a supine position. c. The infusion pump for administering continuous feeding is turned off. d. Interior feeding bag and tubing are not dated. 7. A nurse is caring for a group of clients which of the following tasks is appropriate for the nurse to delegate to the assistive personnel (AP)? (Select all that apply.) a. change addressing for a client who has a stage three decubitus ulcer. b. Measure I&O for a client who is receiving peritoneal dialysis. c. Transfer client from bed to chair with mechanical lift. d. Provide postmortem care on a client who experienced cardiac arrest. e. Obtain a signed consent for a client for a screening colonoscopy. lOMoAR cPSD| 8. A nurse is planning care for a newborn who has hyper bilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include? a. Cloth the newborn in light cotton b. Check the newborns temperature every 8 hours. c. Administer 120 mL of water between feedings. d. Place the newborn 45 cm (18 in) from the light source. 9. An assistive personnel tells the nurse that several client measurements were obtained with morning vital signs. Which of the following clients should the nurse plan to assess? a. A 4-year-old who has a closed head injury and a heart rate of 60/min 10. A nurse is caring for a client following possible exposure to anthrax. Which of the following actions should the nurse take? a. Administer an antitoxin b. Quarantine the client. c. Monitor the client for a productive cough. d. Being prophylactic treatment with ciprofloxacin 11. A nurse is providing teaching about car seat safety to the parent of a term newborn. Which of the following statements by the parent indicates an understanding of the teaching? a. I should place a rolled blanket along each side of my baby's head in the car seat. b. I should place my baby's car seat rear facing until six months of age. c. I should put the car seat retainer clip at the end of my baby's belly button. d. I should position my baby's car seat at a 90-degree angle in the car. 12. A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect? a. Generalized edema b. Elevated urine specific gravity c. Thready pulse d. Increased hematocrit 13. A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse? a. 1 cm of water present in the water seal chamber. b. Tidaling with spontaneous respirations. c. Suction chamber pressure of -20 cm H2O d. Drainage collection chamber is 1/3 full. 14. A nurse is analyzing the laboratory data on a client who has dehydration. Which finding should the nurse anticipate in a client who has fluid volume deficit? a. Decreased serum osmolarity. b. Decreased hematocrit. c. Elevated blood urea nitrogen (BUN) d. lower urine specific gravity 15. A nurse is performing a skin assessment on a client who has risk factors for development of skin cancer. The nurse should understand that a suspicious lesion is a. Asymmetric, with variegated coloring b. Scaly and red. c. Brown, with a wart-like texture. d. Firm and rubbery 16. A community health nurse recognizes that the teen pregnancy rate in the community has increased. Which of the following program planning strategies should the nurse implement first? lOMoAR cPSD| a. Arrange a meeting with teenage mothers who are high school students in the community. 17. After making morning rounds, the charge nurse on the surgical unit delegates the following task to the assistive personnel. which of the following tasks does the nurse direct the AP to complete first? a. Please an NPO sign on the door of a client scheduled surgery b. Set up a room for an expected postoperative admission c. 18. A nurse is caring for a client who is receiving a localized epidural analgesia infusion. Which of the following nurse actions is appropriate? a. Cover insertion site with a transparent dressing. 19. The nurse is performing a disaster triage following a natural disaster. Which of the following should the nurse identify as the highest priority to receive care? a. A client who has agonal respirations. b. A client who has an open skull fracture and is unresponsive c. A client who has traumatic arm amputation d. A client who has a fracture of the femur. 20. A nurse is planning to provide community education about viral hepatitis. Which of the following should the nurse plan to include in the teaching? a. Series for hepatitis vaccine is recommended to prevent viral hepatitis. b. Hepatitis B is transmitted by contaminated food. c. Chronic hepatitis can lead to renal cell cancer. d. Clients who have a history of viral hepatitis are unable to donate blood. 21. A nurse in the emergency department is caring for a client who has abdominal pain. Which of the following actions by the nurse demonstrates veracity? a. The nurse explains the potential risks of treatment. 22. A nurse is about to administer an injection to a client who states, “I don't want that injection. The last time I got that I was sore for a week.” The nurse goes ahead and administers the injection against the clients wishes. The nurse committed which of the following? a. Battery b. Assault c. False Imprisonment d. Libel 23. A home health nurse is assessing a client who is recovering from an acute myocardial infarction (MI). which of the following findings should the nurse report to the provider as a possible indication of left sided heart failure? a. Jugular vein distention b. Weight gain c. Peripheral edema d. Bilateral lung crackles. 24. A nurse is caring for a group of clients. The nurse should request a referral for a speech language pathologist for which of the following clients? a. A client was difficult to the swallowing. 25. A nurse is preparing to provide education about electroconvulsive therapy (ECT) for a client who has major depressive disorder. Which of the following should the nurse include in the teaching? a. A general anesthetic is administered prior to ECT treatments. b. ECT treatments are administered once every 6 months. c. Oral antidepressants are discontinued after ECT treatments. lOMoAR cPSD| d. Implied consent is required prior to ECT treatment. 26. A nurse is caring for a mother who prescribed methadone during pregnancy. The nurse should assess the newborn for which of the following manifestations of neonatal abstinence syndrome? a. Tachypnea b. Irritability c. Tremors 27. A nurse is caring for a client following an open colectomy which of the following findings places the client at risk for delayed wound healing? a. INR 1.1 b. Hyperemesis c. HbA1C 5.6% d. Uncontrolled pain 28. A nurse who typically works on the postpartum unit is assigned to float to the maternal newborn unit. The nurse is very anxious about floating and uncomfortable with the assignment the charge nurse has selected. Which of the following actions is appropriate for the nurse to take? a. As the charge nurse to assign an experienced nurse to act as a resource. 29. A client hospitalized for a bone marrow transplant is in protective isolation while undergoing total body radiation and intense chemotherapy. The client sibling comes to visit but has obvious manifestations of an upper respiratory infection. Which of the following nursing actions is appropriate at this time? a. Allow the sibling to wave at the client through the window or door. b. Allow the sibling to visit after donning a sterile gown, mask and gloves, but prohibit physical contact. c. 30. A nurse is caring for a client following insertion of a subclavian non tunneled percutaneous central venous catheter (CVC). the provider writes a prescription to initiate an IV infusion ringer’s lactate at 150 mL/hour prior to starting the infusion, which of the following actions should the nurse take? a. Review the chest x-ray report. b. Apply oxygen at 3 L/min per nasal cannula c. Flush the catheter with sterile water d. Obtain a peripheral blood glucose level 31. The nurse is providing teaching to an adolescent client who has cystic fibrosis and has a prescription for pancreatic lipase. Which of the following should the nurse include in the teaching? a. Take on an empty stomach. b. Take 1 hour before meals. c. Take 1 hour after meals. d. Take with meals. 32. A nurse is assessing laboratory values on a client who has taken an overdose of acetaminophen. The nurse would expect which of the following laboratory values indicative of organ damage from the overdose? a. Alanine aminotransferase (ALT) 33. A nurse on the orthopedic floor is completing morning assessments on several clients. Which of the following clients has the greatest risk for a fat embolism syndrome (FES)? a. a 24-year-old male who has a casted femur fracture. lOMoAR cPSD| 34. A nurse is caring for a client who has end stage liver disease. The daughter of the client asks about her father's do not resuscitate request. Which of the following is a therapeutic response by the nurse? a. Tell me your feelings about your father's prognosis. 35. A nurse is providing teaching to the parent of preschooler who was newly diagnosed with a latex allergy. The nurse should discuss that a cross reaction may occur with which of the following foods? a. Bananas b. Peanuts c. Shellfish d. Eggs 36. A nurse is planning to admit a client who has hyperthyroidism. Which of the following rooms is appropriate for the nurse to assign the client to? a. A room with a laminar airflow filtration system. b. A room near the nurse’s station c. A room that has a private bathroom. d. A room with a temperature of 20 degrees Celsius. (68 degrees Fahrenheit) 37. A nurse is just returned to the nursing unit following cardiac catheterization. In the immediate post procedure., which of the following is the priority nursing action? a. Monitor the insertion site for infection. b. Check for orthostatic hypotension c. Forcing fluids d. Immobilizing the affected extremity. 38. A nurse is caring for an infant who is being treated for dehydration. Which of the following findings indicate the treatment is effective? a. Flat anterior fontanel. b. Oliguria c. Oral intake of 4 oz. every 3 hours. d. Capillary refill 4 seconds. 39. A nurse is reviewing medical records for four clients. Which of the following represents appropriate documentation? a. Atropine .4mg IV state b. Ativan 1.0 mg IV PRN every 6 hr. c. Carafate 1 g PO 1 hr AC d. Lovenox 30 mg SC every 12 hr. 40. A nurse in the clinic is providing information to a client who has mastitis of the left breast. The client asks the nurse, “does this mean that I must stop nursing my baby?” Which of the following is an appropriate statement by the nurse? a. “No, you can continue to nurse from both your breasts.” b. “Yes, you will have to discontinue breastfeeding.” c. “No, but you should alternate between the right breast and the bottle.” d. “yes, but you can resume nursing when you are done with your antibiotics.” 41. A nursing and mental health clinic is observing clients in the day room period the nurse sits down to talk with an adolescent client who was admitted with clinical depression. After a few minutes of conversation, the adolescent asks the nurse, “why did you choose to talk to me out of this room full of kids?” Which of the following responses by the nurse is therapeutic? a. You looked like you would be the most likely to talk back with me. lOMoAR cPSD| b. Let’s go see what activities are going on outside. c. Why shouldn’t I talk to you? You looked lonely. d. “You're curious why I am interested in you and not the others?” 42. A nurse working in an inpatient mental health facility observes a client who is agitated and threatening staff members in the dayroom. Which of the following actions should the nurse take first? a. Accompany the client away from the common area. 43. A client who is precepting in nursing student who brings the following client observations to the nurse’s attention. Which of the following client should the nurse assess first? a. A client who is 3 hours post foley catheter removal and has not voided. b. A client who is 3 days postoperative colectomy with a large, loose melena stool. c. A client who is 1 day postoperative following a total hip replacement with a pain level of 7 on a scale of 0 to 10. d. A client who is coughing up pink-tinged sputum following a bronchoscopy and lung biopsy 1 hour ago. 44. A nurse is planning teaching for a client who is at 10 weeks gestation and has a history of urinary tract infections. Which of the following information should the nurse plan to include in the teaching about UTI prevention? a. Decrease intake of citrus foods and beverages. b. Wear nylon underwear. c. Empty the bladder before and after intercourse. d. Increase the time between voiding. 45. A nurse in the emergency department is providing discharge teaching to a client who has a sprained ankle. For the 1st 24 hours following injury, the nurse should instruct the client to do which of the following? a. intermittently place ice on the ankle. 46. After evaluating the morning laboratory results on several clients, the provider writes prescriptions for four clients assigned to the nurse’s care. Which of the following prescriptions is the nurse’s highest priority? a. Administer vitamin K 10 mg to a client on warfarin with an INR of 6. 47. A nurse is caring for a client who has ruptured ribs, has developed thrombophlebitis, and is being treated with a heparin drip. The client develops hematuria and has an activated partial thromboplastin time (aPTT) of 100 seconds. which of the following should the nurse take first? a. Turn off the heparin drip. 48. A nurse is caring for a client who has a hearing impairment. When speaking to the client, the nurse should incorporate which of the following communication methods? a. Speak directly into one of the client’s ears. b. Rephrase sentences the client does not understand. c. Drop voice volume at the end of sentences. d. Exaggerate lip movements. 49. A nurse is reviewing morning laboratory values for several clients. Which of the following findings is the highest priority for the nurse to report to the provider? a. A client who has syndrome of inappropriate antidiuretic hormone and has a sodium level of 128 mEq/L. b. The client who is prescribed digoxin and furosemide and has a potassium level of 3.1 mEq/L. c. A client who has chronic emphysema and a PCO2 of 50 mm Hg. lOMoAR cPSD| d. A client who has sepsis and a WBC of 15/mm3. 50. A nurse is caring for a client who has a new prescription for chlorpromazine by IM injection. which of the following is an appropriate action? a. Check orthostatic blood pressure one hour after administration. 51. A nurse is caring for a postoperative client. Which of the following interventions will reduce the risk of deep vein thrombosis? a. Apply venous plexus foot pumps. 52. A nurse is caring for a client who is manic period which of the following activities is appropriate for the nurse to suggest? a. taking a daily walk on the hospital grounds. 53. The nurse is planning to perform wound irrigation for a client who has an open secondary wound. When creating a sterile field, which of the following actions should the nurse take? a. Step up the sterile field 7.6 cm below waist level. b. Hold the bottle of sterile solution with the palm over the label while pouring. c. Place the sterile items within 1 cm of the edge of the sterile border. d. Place the lid of a bottle of sterile solution within the sterile field. 54. A nurse is reviewing the history and physical on a client who has right ventricular heart failure. Which of the following is an expected finding? a. Crepitus b. Elevated pulmonary artery pressure. c. Hepatosplenomegaly d. Confusion 55. A nurse is assisting a client with schizophrenia. Which of the following findings is the nurse’s priority? a. A client asks other clients on the unit for help with bathing and getting dressed. b. The client refuses to take prescribed oral risperidone. c. The client reports hearing voices. d. The client’s thoughts jump rapidly from one idea to the next when speaking. 56. A nurse is providing postoperative teaching to a client who has a newly inserted pacemaker. Which of the following statements by the client indicates that the teaching has been effective? a. “I'll use my cell phone on the ear opposite of my pacemaker.” 57. A charge nurse in the emergency Department is receiving the data of four young children who are receiving treatment. Which of the following should alert the charge nurse to the possibility of child abuse? a. A 9-month-old Infant who is dressed inappropriately for the current weather conditions. 58. A nurse is providing discharge teaching to a client who is postpartum and plans to breast feed. Which of the following should the nurse recommend the client to increase in her diet during lactation? a. Vitamin D. b. Iron. c. Vitamin A d. Calcium. 59. A nurse in the post anesthesia care unit is caring for four post-operative clients. The nurse realizes that coughing poses a risk to which of the following clients? a. A client who had a thyroidectomy. 60. A home health nurse is admitting a client was prescribed peritoneal dialysis. Which of the following actions should the nurse initiate first? lOMoAR cPSD| a. Demonstrate how to perform the procedure. 61. A visiting nurse is writing a plan of care for a client who is homebound and has stage two Alzheimer's disease. Which of the following should the nurse include in the plan of care? a. Educate family about loss of family recognition. 62. A nurse is specs another nurse is chemically impaired during the shift. Which of the following is an appropriate action for the nurse to take? a. Report to the nurse manager. 63. The nurse is preparing to administer potassium chloride intravenously to a client who has hypokalemia. The client is receiving a current infusion of 0.9% sodium chloride at 125 mL/hr. which of the following actions to the nurse plan to take? a. Dilute the solution prior to infusion. 64. A nurse is admitting an unidentified female infant who was brought to the emergency Department. Based on the assessment findings, the nurse should estimate the infants age to be which of the following? a. Six months. 65. A nurse is preparing to administer eye drops to a client. Which the following nursing actions is appropriate? a. Have the client tilt her head slightly so that the medication enters the nasal lacrimal duct. b. Gently wash away any exudate along the eyelid margin from the outside towards the inner canthus. c. Use aseptic technique and drop the medication into the conjunctival sac. d. Drop prescribed number of drops onto the cornea. 66. A nurse is caring for a client who reports the use of chondroitin and glucosamine. The health benefit of this supplement combination is to do which of the following? a. Treat mild to moderate depression. b. Enhance the immune system c. Prevent and treat prostate enlargement. d. Improve joint functioning. 67. A nurse is performing a nutritional assessment on a client who has calcium deficiency. The nurse should identify that the client is at risk for which of the following? a. Tetany b. Anemia c. Osteogenesis d. Osteoarthritis 68. A nurse is assessing a client who has systemic lupus erythematous (SLE). which of the following is an Expected finding? a. Dry, raised facial rash. 69. A nurse is assessing a client who is 8 hours post-operative following a right modified radical mastectomy. Which of the following should the nurse recognize as the priority finding? a. Coughing frothy, pink secretions b. Urinary output of 100 mL in 4 hours. c. Emesis of 110 mL of thick yellow fluid d. Red drainage on the dressing 70. A nurse in a provider’s office is caring for a client who has Parkinson's disease and has been taking level dopa for the past five weeks. The client reports a new onset of muscle twitching. Which of the following statements by the nurse is appropriate? a. “This is a manifestation of drug toxicity and may require a dosage reduction.” lOMoAR cPSD| 71. A nurse in the labor and delivery unit is receiving medications for a group of clients. Which of the following medications places the fetus at risk for teratogenic effects? a. Levothyroxine for hypothyroidism b. Phenytoin for seizure disorder. c. Magnesium oxide for constipation d. Ferrous sulfate for chronic anemia. 72. The nurse is providing discharge teaching about disease prevention to a client who has active tuberculosis. Which of the following should the nurse include? a. Educate the client how to cover nose and mouth with tissue when coughing. b. Recommending the client may return to work after two negative sputum cultures. c. Instructing the client that he is no longer contagious after 1 week of medication therapy. d. Teaching the client’s family to wear protective masks while with the client. 73. A nurse is planning care for a client who has neutropenia. Which of the following nursing interventions is appropriate to include in the care plan? a. Remove fresh Flowers from the client's room. 74. A nurse is planning to change the dressing of a school age child who has sustained multiple burns. Which of the following actions should the nurse plan to take? a. Apply the dressing in a proximal to distal pattern. 75. An older adult client tells the nurse, “I thought immunizations were for kids.” The nurse informs the client that older adults should receive which of the following immunizations? a. Herpes zoster vaccine. 76. A nurse is caring for a client who was involuntarily admitted to the psychiatric unit following a failed suicide attempt. the provider prescribed the medication that is part of an experimental treatment. Which of the following actions should the nurse take? a. Explain the risks and benefits associated with the experimental treatment. b. Withhold the medication until the client’s next of kin can give consent. c. Witness consent before medication administration. d. Exclude the client from the study due to involuntary admission. 77. A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication? a. Decreased reflexes b. Weight gain of 1.4 kg. c. Increased urinary output d. Jugular vein distention. 78. A nurse is assessing a client who is preparing for surgery. The client tells the nurse, “If something happens to me from which I cannot recover I don't want to go on a ventilator.” Which of the following is an appropriate response by the nurse? a. You're concerned that something may go wrong? b. Don’t stress so much, everything will be fine. c. I would make the same decision. d. Why wouldn’t you want life-saving measures performed? 79. A nurse is interviewing a client who presents with multiple injuries that are consistent with intimate partner abuse. After establishing his trust and report which of the following should the nurse say? a. Has your partner physically hurt you before? 80. A nurse is caring for a client who reports chest pain. Which of the following laboratory findings indicates myocardial damage? lOMoAR cPSD| a. aPTT 80 secs b. Troponin I 1.8 ng/mL c. ESR 17 MM/HR d. Human B type 81. A nurse is caring for a client who is prescribed for assamite. The nurse understands this medication is used to treat which of the following client conditions? a. Rales in lower lobes of lungs. 82. The nurse manager at a public health clinic is concerned about the rising number of sexually transmitted infections in the community. The purpose of which of the following is to generate new ideas to address the public health concern? a. A brainstorming session with nurses. b. A community wide program. c. Role playing with nurses. d. Personal discussions with clients. 83. A nurse on the medical surgical unit is caring for a group of clients. Which of the following clients would benefit from a three-way indwelling catheter? a. A female client who is prone to development of blood clots in the urine. b. A female client who has a history of chronic urinary tract infections c. A male client who has spontaneous bladder emptying. d. A male client who has postoperative acute urinary retention. 84. A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? a. The provider should renew the prescription for restraints every 48 hours. b. The nurse should pad the bony prominences. c. The nurse should remove the restraints every two hours. d. The nurse should tie the restraints using a square knot. e. The providers prescription should include the type of restraint to use. 85. A nurse supervisor receives notification of a disaster in the community and the possibility for multiple admissions to the facility. Which of the following clients through the nurse recommend for discharge? a. The client who is one day postoperative laparoscopic cholecystectomy whose temperature is 37.3 C. 86. A nurse is admitting a client who has chronic gout. The nurse anticipates which of the following provider prescriptions? a. Allopurinol 87. A nurse is caring for a client who is 2 days postoperative following a lumbar laminectomy and is reporting nausea. Which of the following actions should the nurse take first? a. Administer an anti-emetic. 88. A nurse in the recovery room is assessing a client who has a new chest tube. The nurse finds that the water seal is no longer tidaling. The nurse should identify these findings as a result from which of the following? a. An air leak noted at the insertion site. b. The tubing may be kinked. c. Water needs to be added to the suction control chamber. d. The suction is set too low. lOMoAR cPSD| 89. An assistive personnel at a long term care facility reports to the nurse that another AP has spent the entire morning on the phone and has not completed the morning assignment. Which of the following is inappropriate action by the nurse? a. Ask the AP what work remains to be completed on the assignment. 90. The community health nurse is completing a newborn home visit and observes family members smoking cigarettes in the house. Which of the following is a priority intervention? a. Suggest smoking cessation strategies to family members. 91. A nurse is teaching a prenatal class about evidence of effective breast feeding to a group of parents. Which of the following information should be included? a. Newborn swallowing sounds are audible while breastfeeding. b. Newborn stools are yellow and seedy after seven days of breastfeeding. c. Maternal breast becomes soft following feedings. 92. A nurse is caring for a client who will be having a transfusion of platelets. The nurse recognizes that the outcome of will be which of the following? a. Decrease in bleeding, from puncture sites 93. A nurse in a prenatal clinic is caring for an adolescent client who is now in her third trimester of pregnancy. The nurse identifies that the client is at an increased risk for which of the following? a. Postpartum depression. 94. A nurse is planning dietary intervention for a client who is immobile due to pelvic and femur fractures. Which of the following should the nurse include in the plan? a. Provide a low-iron diet. b. Provide a high-phosphorus diet. c. Provide a low-fiber diet. d. Provide a high protein diet. 95. A home health nurse is providing teaching about self-administration of insulin to a client who is newly diagnosed with diabetes. Which of the following statements by the client is a need for further teaching? a. I will gently massage the injection site following administration. 96. A school nurse is assessing a child who has scabies. Which of the following is an expected finding? a. White nits on the hair shaft near the child’s scalp b. Yellow, crusted lesions on the child’s face. c. Grayish-brown pruritic lesions on the child’s feet and ankles. d. Red, itchy papules on the child's groin area. 97. A nurse is caring for a client who is postoperative and at risk for development of deep vein thrombosis. Which of the following should the nurse identify as increasing the risk of developing venous stasis? a. Prolonged bed rest. 98. A nurse is caring for a client who is receiving enteral nutrition. Which of the following findings indicates a need to decrease the rate of the enteral feeding? a. Constipation. 99. A nurse is assessing a client one week after a successful bone marrow transplant. The client reports peeling of skin on her hands and feet. The nurse should recognize this desquamation as an indication of which of the following complications? a. Failure to engraft b. Veno-occlusive disease c. Graft - versus - host disease lOMoAR cPSD| d. Pancytopenia 100. A nurse is providing education to a mother of a toddler who has pertussis. Which of the following statements by the parent indicates the teaching has been effective? a. My child’s symptoms will be gone in 14 days. b. If I get pregnant, I should check with my provider about receiving a pertussis booster. c. My child will take prophylactic antibiotics for 6 months to prevent recurrence. d. I will develop a rash on my abdomen if I contract the illness. 101. A nurse at the family planning clinic triages several clients over the phone. Which of the following clients should the nurse instruct to come to the clinic? a. A client who uses a diaphragm for contraception and has lost 30 lb in the past 6 months dieting. b. A client who had an intrauterine device inserted yesterday and has cramping and bleeding c. A client who has started taking oral contraceptives and is experiencing bright red vaginal breakthrough bleeding. d. A client who has sharp pain in her shoulder following a laparoscopic tubal ligation yesterday. 102. A nurse in the pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions? a. Pertussis. 103. A nurse is planning the discharge of an infant who has tetralogy of Fallot. The nurse anticipates the need for which of the following equipment? a. Portable suction b. Cervical collar c. Hemodialyzer d. Pulse oximeter 104. The nurse is admitting a client to the medical surgical unit. Which of the following actions should the nurse take first? a. Place the client’s valuable in the facility’s safe. b. Observe the client's level of mobility. c. Administer prescribed medications. d. Electronically enter the prescriptions from the provider. 105. A charge nurse on the pediatric unit is making assignments for a float nurse from the medical unit. Which of the following clients is appropriate to assign the float nurse? a. A 10-year-old client who has pneumonia and is receiving respiratory treatments. b. A 4-year-old client who has a Wilms tumor and is receiving chemotherapy. c. An 8-month-old client who is scheduled for a surgical repair of a ventricular septal defect tomorrow. d. A 14-year-old client who is scheduled for discharge today following placement of a Herrington rod. 106. A nursing and residential mental health facility is planning care for a new client who has obsessive compulsive disorder (OCD). Which of the following is appropriate for the nurse to include in the plan of care? a. Work with the client to create a flexible daily schedule. b. Gradually decrease the time allowed for ritualistic behavior. c. Offer solutions to assist in problem solving d. Teach the client to meditate about obsessive thoughts. lOMoAR cPSD| 107. A nurse delegates tasks to an LPN and AP. when admitting a client who is experiencing acute liver failure, and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN? a. Insert an indwelling catheter if the client has not voided in 3 hours. b. Obtain the abdominal girth now and every 4 hours. c. Assess and document the level of consciousness every hour. d. Measure the amount of gastric drainage every two hours. 108. A nurse is preparing to provide discharge teaching to a client who has an ileal conduit due to treatment for bladder cancer. which of the following instructions to the nurse include in the teaching? a. Clean the skin around the stoma with a moisturizing soap. 109. A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions by the nurse is appropriate? a. Monitor for abdominal ascites. b. Implement a low-carbohydrate diet. c. Review serum amylase levels d. Place warm compresses on area of pruritus. 110. a nurse is providing teaching to the parent of a child who has pediculosis capitis. Which of the following information should be included in the teaching? a. Spray car seat covers with an antimicrobial solution b. Use a stiff bristled brush to clean furniture c. Store non washable items in plastic bags for 14 days d. Use an anthelmintic medication for 7 days. 111. a nurse is teaching a client who has left leg weakness how to use a standard Walker. Which of the following actions by the client indicates a need for further teaching? a. The client places the walker 2 feet forward with each step. b. Moves with left leg and the walker ahead together. c. Holds the walker 6 inches below waist level with elbows flexed. d. Lifts the walker when moving it forward. 112. A nurse is caring for a client who has just returned in the unit following a bronchoscopy. Which of the following actions by the assistive personnel requires the nurse to intervene? a. Encourages the client to use the incentive spirometer. b. Elevates the head of the client’s bed. c. Offers oral fluids to the client. d. Checks the client’s pulse oximetry 113. A nurse is caring for a client who is 2 hours postoperative following an ileal conduit procedure for bladder cancer. For which of the following findings should the nurse notify the provider? a. A dusky colored stoma b. Absence of bowel sounds c. Serosanguineous drainage d. Urinary output 40 mL/hour. 114. A nurse is providing teaching for the parents of a school age boy who has hemophilia. The parents tell the nurse that the child loves soccer. The child is adamant about playing with his peers on the school team next year, and the parents state that, “we are unable to say anything to convince him that it is impossible.” Which of the following is an appropriate suggestion? lOMoAR cPSD| a. Encourage the child to be involved with the soccer team as the coaches assistant or team manager. 115. A nurse is caring for a client who has a diagnosis of HIV. Which of the following client statements should the nurse address first? a. I am lonely because I don't have anyone to talk to. b. I can’t seem to gain any weight. c. I lost my job last week and now I don’t have health insurance d. I’ve been living in a homeless shelter for the last week. 116. The nurse is caring for a client who has a left femur fracture it is in a skeletal traction. The client reports pain due to muscle spasms in the affected leg. Which of the following action is appropriate by the nurse? a. Increase the amount of traction. 117. Nurse educators discussing about modes of transmission with nursing students. Which of the following statements should the nurse educator include as an example of a vector borne transmission? a. Transmission of West Nile virus from a mosquito bite. 118. A nurse is creating an activity plan for a homebound older adult client. In the planning the nurse considers the physiologic changes that may affect pulmonary function related to the normal aging process. Which of the following age-related physiological changes should the nurse consider in the plan? a. Decrease blood oxygenation. 119. An emergency department nurse triage is a group of schoolchildren injured in a school bus crash. Which of the following children should the nurse have the provider evaluate first? a. A child who has a forehead wound that is bleeding copiously. b. A child who has a compound fracture of the femur and is crying in pain. c. A child who reports diplopia and nausea and was unconscious at the scene but is now awake. d. A child who has several missing permanent teeth and a swollen, ecchymotic upper lip. 120. A nurse plans to ambulate a client on the third day after cardiac surgery. Which of the following interventions should the nurse take so that the client will best tolerate and ambulation? a. Provide the client with water. b. Pre medicate the client with the prescribed analgesic. c. Obtain the client’s vital signs and oximetry prior to ambulation. d. Reinforce the client’s surgical dressing. 121. A nurse is electronically documenting assessment findings for client. Which of the following is an example of subjective data? a. The client reports a pain level of 6 on a scale of 0 to 10. 122. A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket. After moving the client to safety which of the following is the priority action? a. Notify the facility operator. b. Close the fire doors on the unit. c. Turn off oxygen sources. d. Put out the fire with the appropriate extinguisher. 123. A nurse is caring for a client who has a diagnosis of antisocial personality disorder. The nurse should expect the client to demonstrate which of the following? a. Magical thinking b. Mood swings lOMoAR cPSD| c. Ritualistic behaviors d. Poor impulse control. 124. A client who has a diagnosis of complete placenta previa is admitted to the labor and delivery suite at 36 weeks gestation with contractions every five minutes in frequency and 1 in in duration. which actions should the nurse take? a. Rupture the amniotic sac. b. Medicate the client for pain. c. Prepare the client for a cesarean section. d. Perform a vaginal exam. 125. A nurse is planning care for a child who is unresponsive and has increased intracranial pressure (ICP). Which of the following actions should the nurse take? a. Schedule routine oral suctioning b. Pad side rails of the bed. c. Obtain isolation supplies d. Place the child in the Trendelenburg position 126. A nurse is planning care for a client who takes haloperidol for the treatment of schizophrenia. Which of the following should the nurse include in the plan of care? a. Monitor the client for hypothermia. b. Screen the client for tardive dyskinesia. c. Check the client’s weekly potassium level. d. Schedule the client for a 24-hour urine collection 127. A nurse is caring for a client who was involved in a motor vehicle crash. The client reports shortness of breath in chest pain and asks the nurse, “am I dying?” Which of the following actions should the nurse take first? a. Obtaining pulse oximetry reading. 128. A nurse is caring for a client who is receiving gentamicin. Which of the following findings indicates the client is developing toxicity? a. Tinnitus. 129. The nurse is caring for a client who has just given birth to a stillborn newborn. Which of the following is the priority task for the nurse to facilitate the clients grieving process? a. acknowledging the reality of the newborn's death. 130. A nurse is teaching a client who has a new diagnosis of gastroesophageal reflux disease. Which of the following instructions should the nurse include in the teaching? a. Sleep with the head of bed elevated. 131. A nurse is caring for a client who has atypical depression and is taking phenelzine. Which of the following is appropriate for the nurse to offer as an evening snack? a. Low fat yogurt 132. A nurse is at mitting an infant who has bacterial meningitis. Which of the following actions should the nurse take first? a. Administer cefazolin. 133. A client asked the nurse if it is safe for him to take a glucosamine supplement. The nurse should assess for which of the following potential contraindications? a. Shellfish allergy. 134. A nurse is analyzing the cardiac rhythms of for telemetry clients in the coronary care unit. Identify the rhythm strip that the nurse would recognize as indicative of a client who should be receiving warfarin? a. Rhythm C lOMoAR cPSD| 135. A nurse in a postpartum unit is caring for several clients. After receiving a change of shift which of the following clients should the nurse assess first? a. A client who is 2 days postpartum and whose fundus is 2 fingerbreadths below the umbilicus. b. A client who is 1 day postpartum and has not voided in 8 hours. c. A client who is 3 days postpartum and has not had a bowel movement since prior to admission. d. A client who is 4 days postpartum and has lochia serosa. 136. The nurse is teaching a client and their family about hospice care. Which of the following information should the nurse include in the teaching? a. Hospice care improves quality of life thorough palliative care. b. Hospice care provides 24 hours, in home care. c. Hospice care is intended to postpone death. d. Hospice care encourages the family to coordinate health care services. 137. And infection control nurse is reviewing care procedures for four clients. Which of the following requires a nurse to intervene? a. A client who has pulmonary tuberculosis and is placed in a positive pressure room. 138. A nurse is caring for a client who is at high risk for developing diabetes insipidus following a severe head injury. Which assessment findings indicates to the nurse that the client is developing diabetes insipidus? a. Urine specific gravity of 1.028. b. Urine output of 250 mL/hour. c. Serum sodium of 155 mEq/L d. Blood glucose of 198 mg/dL 139. A nurse is providing teaching for the client who has a new prescription for lithium carbonate. Which of the following should the nurse include in the teaching? a. Diarrhea is an indication of toxicity. 140. a nurse is caring for an adolescent client who has no previous history of a seizure disorder. The patient was admitted after having a 3-minute tonic clonic seizure two weeks after sustaining a mild concussion. The client is scheduled to have an electroencephalogram (EEG) in the morning. for breakfast, the client orders coffee and a donut. Which of the following nursing actions is appropriate at this time? a. Explain that the client may not have coffee prior to the EEG. 141. A nurse is planning care for a client who is comatose and has a stage two decubitus ulcer on the coccyx. Which of the following interventions is appropriate to include in the plan of care? a. Provide the client with an alternating pressure mattress. 142. A nurse is preparing a client for surgery and has just administered the preoperative injection. Which of the following actions should the nurse take? a. Take the client to the bathroom to void. b. Ask the client to verify the surgical site. c. Review deep breathing and coughing exercises. d. Raise the side rails of the bed. 143. A nurse is performing postmortem care on an older adult client. Which of the following action is appropriate to take? a. Lower the head of the bed to a supine position. 144. A nurse in the emergency Department is caring for a client following a motor vehicle crash. Which of the following actions to the nurse take first? lOMoAR cPSD| a. Stabilize the cervical spine. 145. The nurse is reviewing the employee health program for new employees. Which of the following diagnostic assessments should the nurse recommend for all new employees to screen for the presence of tuberculosis? a. Sputum culture b. Chest x-ray c. QuantiFERON-TB Gold blood analysis d. Mantoux test 146. A nurse volunteers to assist after witnessing a mass casualty incident involving a train derailment. Which of the following clients to the nurse immediately in completely immobilize? a. A client who has a Glasgow Coma Score of 4. 147. A nurse in a newborn nursery is performing assessments on four neonates that are all less than 24 hours old. The nurse should plan to notify the provider of which of the following findings? a. Head circumference 1 cm greater than chest b. Positive Babinski reflex on bilateral feet c. Passage of meconium stool d. Pinna below the outer canthus of the eye 148. A nurse is providing dietary teaching for a client who has a history of nephrolithiasis. Which of the following is appropriate to include in the teaching? a. Limit fluid intake to 40 oz/day. b. Decrease complex carbohydrates in the diet c. Avoid foods that have high levels of oxalates. d. Restrict dietary calcium intake. 149. A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following suggestions should the nurse recommend? a. Encourage the client to ambulate in the hallway 1 hour before bedtime. b. Tell the client to avoid drinking fluids 1 hour before bedtime. c. Schedule routine care tasks during hours when the client is awake d. Eat bedtime snack containing carbohydrates. 150. An immunity health nurse is planning to make home visits to several clients who all live within a few miles’ radius of the office. Which of the following clients should the nurse plan to visit first? a. A legally blind client who has diabetes mellitus and whose insulin syringes need to be prefilled for the coming week. 151. A nurse is teaching a client who has a new prescription for digoxin. which of the following should the nurse include in the teaching? a. “Notify your provider if you experience muscle weakness.” b. Reports a weight gain of one-half pound per day. c. Expect this medication to increase your blood pressure. d. You will need to take a diuretic while taking this medication. 152. A nurse is caring for a client who is receiving IV antibiotics and tests positive for C. difficile. which of the following actions by the nurse is appropriate? a. Place the client on contact precautions. 153. A charge nurse is creating assignments for the next shift for several nurses and one of the nurses is pregnant. Which of the following clients should the charge nurse assigned to a nurse who is not pregnant? lOMoAR cPSD| a. An 80-year-old client who has alcoholic pancreatitis and is being treated for impetigo. b. A 60-year-old client who is recovering from shingles. c. A 40-year-old client who is suspected of having tuberculosis. d. A 20-year-old client who is HIV positive. 154. A nurse in an inpatient psychiatric unit is setting short term goals for an adolescent client who was admitted for treatment of anorexia nervosa. Which of the following is an appropriate short-term goal the nurse should set? a. The client will develop a personalized meal plan. 155. A nurse is caring for a preschool age child who has a short leg, plaster cast applied one hour ago. Which of the following is an appropriate intervention? a. Support the affected leg on a pillow. 156. A nurse is assessing a client who is gravida 2, para 1. the client is at 41 weeks of gestation and is receiving oxytocin for the augmentation of Labor. The nurse should decrease the infusion rate for which of the following findings? a. Contractions are strong to palpation b. Cervix is dilating at 1 cm every 4 hours. c. Consistent contractions lasting 80 seconds. d. Contractions occur every 90 seconds. 157. A home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The nurse should evaluate which of the following laboratory tests to determine effective longterm management of blood glucose levels? a. 3-hour oral glucose tolerance test. b. HbA1C c. Fasting blood glucose test d. Urinalysis for ketones 158. A nurse is preparing to obtain informed consent for a colonoscopy from a client who does not speak English. Which of the following actions should the nurse take? a. Ask the health care interpreter to explain the procedure. 159. The nurse manager is presenting an in service for newly licensed nurses about the advanced directives. Which of the following statements by a new nurse indicates a need for further teaching? a. Advanced directives must be notarized to be legally implemented. 160. A nurse is discussing a living will with the client. Which of the following statements by the client indicates an understanding of this document? a. It expresses my wishes about distribution of my belongings after death. b. It designates a family member to make my health care decisions. c. It is required for anyone undergoing surgery. d. It communicates my wishes for end-of-life care. 161. A home health nurse is doing an in-home assessment for an older adult client who is at risk for falls. Which of the following assessment findings should the nurse identify as a potential hazard for the client? a. Electrical cord secured to the baseboards. 162. A nurse in an emergency department is assessing a client who has a nasal fracture. Which of the following findings should cause the nurse to suspect a skull fracture? a. Clear fluid drainage from the nares. b. Report of pain around the eyes. c. Dried blood in the mouth. lOMoAR cPSD| d. Mandibular asymmetry. 163. A nurse documents that a client recovering from a close head injury assumes a decerebrate posture in response to stimuli. Which of the following illustration indicates the client's positioning? a. Posture D 164. You nurse manager is making staffing assignments for the medical surgical unit. Which of the following clients is appropriate to assign to a float nurse from the postpartum unit? a. A client was two days postoperative following a colon resection. 165. A nurse is caring for a client who has a newly implanted sealed internal radiation device to treat cervical cancer. Which of the following is an appropriate action for the nurse to take? a. Prohibit visitors for the first 24 hours. b. Keep a 3-foot distance from the radiation implant c. Maintain the client on bed rest for 72 hours. d. Require the client to wear a dosimeter badge. 166. During the immediate postoperative period following thoracic surgery, the nurse medicates a client for pain on a schedule. The rationale for this nursing action is which of the following? a. Suppresses the cough reflex b. Decrease the level of anxiety. c. Reduces the respiratory rate. d. Facilitates deep breathing. 167. At the start of the evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first? a. Constipation. b. Indigestion c. Swollen ankles d. Urinary frequency 168. A nurse is discussing the Z-track administration of hydroxyzine hydrochloride with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique? a. This technique decreases the risk of subcutaneous infiltration. b. This technique prevents injury to the sciatic nerve. c. This technique allows a larger amount of medication to be injected. d. This technique increases the absorption rate of the drug. 169. The nurse is caring for a client who is experiencing acute mania. Which of the following actions should the nurse include in the plan of care? a. Provide a flexible activity schedule. b. Provide high calorie nutritional supplements. c. Allow the client to eat meals alone in her room. d. Allow the client to choose her clothes independently. 170. A nurse is evaluating the results of the above urinalysis done for a preschool age child. The nurse should identify that these findings are consistent with which of the following renal disorders? a. Nephrotic syndrome. 171. Nurses preparing to administer vancomycin to a client who has an infected wound. The nurse should plan to monitor for which of the following adverse reactions? a. Hepatotoxicity lOMoAR cPSD| b. Ototoxicity c. Hypercalcemia d. Hypertension 172. Nurse is teaching a client who has a low literacy level about home management diabetes mellitus. which of the following actions is appropriate? a. Show the client and educational video. 173. A nurse is assessing a client who is 2 hours postoperative following insertion of a chest tube connected to a chest drainage system as depicted in the photo above. which of the following is an expected finding? a. Fluctuation of the fluid level in chamber B 174. A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client has two school-age children and a limited support system. Which of the following is the priority nursing action? a. Inform the client of available community resources. b. Assist the client in finding childcare options c. Agree upon short-term goals for the client. d. Ask the client about their understanding of the diagnosis. 175. A nurse is giving a change of shift report about the client who is 36 hours postoperative to another nurse. Which of the following should the nurse include? a. Daily bath given at 1000 b. Vomited a large amount of emesis immediately after surgery. c. Flushed IV with 0.9% sodium chloride. d. Pain relieved by position change. 176. A nurse in the mental health clinic is reviewing the history in physical for a 17-year-old client who has a new diagnosis of social phobia. Which of the following is an expected finding? a. Client reports minimal alterations in performance at a part time job. 177. A nurse is assessing a client who has an IV infusing at gravity at 125 mL/hour. which of the following assessments indicates to the nurse that the IV site needs to be changed? a. The area around the IV site is reddened. 178. Nurse is caring for a client who has a new prescription for lithium carbonate prior to administering the dose, which of the following laboratory values should the nurse evaluate? a. Arterial blood gases b. Total cholesterol c. Thyroid hormones d. Hemoglobin 179. A nurse is assessing a client who is postoperative following abdominal surgery. The client states, “I feel like my incision ripped open.” The nurse notes dehiscence of the incision. which of the following actions should the nurse take? a. Extend the client’s legs above heart level b. Place the client in low fowlers position. c. Instruct the client to perform the Valsalva maneuver d. Apply a dry gauze dressing to the incision. 180. A nurse at a public health clinic is caring for a group of clients. Which of the following should the nurse identify as a reportable diagnosis to the CDC? a. Herpes simplex virus (HSV) type 1 b. Hepatitis A c. Human papillomavirus (HPV) lOMoAR cPSD| d. Pediculosis capitis 181. A nurse on a medical unit has just received change of shift report. Which of the following clients should the nurse assess first? a. A 68-year-old client who is 2 days post myocardial infarction (MI) and reports chest pain at a 4 on a 0 to 10 scale. b. A 48-year-old client who has AIDS, pneumocystis pneumonia, and a temperature of 38.3 C (101 F). c. A 60-year-old client who had COPD, is receiving 2 L/min O2 via a nasal cannula and has an oxygen saturation of 89%. d. A 26-year-old female client who has pelvic inflammatory disease and is unable to void. 182. At the beginning of the day shift, a team leader delegates the following tasks to the assistive personnel (AP); bathe four clients, distribute fresh water, and obtain the morning vital signs. At noon, the nurse asks the AP to transport one client to physical therapy. The AP reports two clients still need bed baths. Which of the following is an appropriate strategy for the nurse to delegate more effectively in the future? a. Plan a more reasonable job assignment b. Co-assign a more qualified individual to assist the AP. c. Set a clear time for the completion of each task. d. Volunteer to give the baths for the AP.