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ATI Fundamentals Proctored Exam Question and Answers

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ATI Fundamentals Proctored Exam Question and Answers

ATI Fundamentals Proctored Exam Question and Answers With Rationales

ATI Fundamentals Proctored Exam Test Bank 2019 / 2020 / 2021

1. A nurse is planning to collect a stool specimen for ova and parasites from a client who has
diarrhea. Which of the following actions should the nurse take when collecting the specimen?
A. Instruct the client to defecate into the toilet bowl
-The nurse should have the client defecate into a bedpan or a container for stool
collection. The toilet water can dilute and contaminate the liquid specimen.
B. Transfer the specimen to a sterile container
-The nurse should place the stool specimen in a clean container using a tongue
depressor.
C. Refrigerate the collected specimen
-The nurse should send the collected stool specimen immediately to the laboratory
after labeling the specimen properly to prevent contamination with microorganisms and keep the
specimen from getting cold.
D. Place the stool specimen collection container in a biohazard bag
-The nurse should place the specimen collection container in a biohazard bag with the client
label on the container and the bag for easy identification. This will also prevent contamination
with microorganisms.
2. A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the
following actions should the nurse take?
A. Hyper oxygenate the client before suctioning
-The nurse should use a manual resuscitation bag to hyper oxygenate the client for several
minutes prior to suctioning.
B. Insert the catheter during exhalation
-The nurse should insert the catheter during inhalation
C. Apply suction during insertion of the catheter
-Applying suction while inserting the catheter increases the risk of damage to the
tracheal mucosa and removes oxygen from the airways.
D. Apply suction for no more than 15 secs
-The nurse should apply suction for no more than 10 seconds
3. A nurse is providing teaching to a client regarding protein intake. Which of the following
foods should the nurse include as an example of an incomplete protein?
A. Eggs
-this is a complete protein, contains all of the essential amino acids necessary for the
synthesis of protein in the body.
B. Soybeans
-this is a complete protein, contains all of the essential amino acids necessary for the
synthesis of protein in the body.

C. Lentils
-Incomplete proteins are missing 1 or more of the essential amino acids necessary for the
synthesis of protein in the body. Examples of incomplete proteins include lentils, vegetables,
grains, nuts, and seeds.
D. Yogurt
-this is a complete protein, contains all of the essential amino acids necessary for the
synthesis of protein in the body.
4. A nurse is caring for a client who was admitted to a long-term care facility for rehabilitation
after a total hip arthroplasty. At which of the following times should the nurse begin discharge
planning?
A. One week prior to the client’s discharge
-Beginning to plan for the client’s discharge a week prior to the event might not allow
sufficient time for planning. The nurse should begin discharge planning at the time of admission.
B. Upon the client’s admission to the care facility
-The nurse should begin discharge planning at the time that the client is admitted to the facility.
C. Once the discharge date is identified
-Beginning to plan for the client’s discharge once the discharge date is identified might
not allow sufficient time for planning. The nurse should begin discharge planning at the time of
admission.
D. When the client addresses the topic with the nurse
-Beginning to plan for the client’s discharge once the discharge date is identified might
not allow sufficient time for planning. The nurse should begin discharge planning at the time of
admission.
104. A nurse is explaining the use of written consent forms to a newly licensed nurse. The nurse
should ensure that a written consent form has been signed by which of the following clients?
A. A client who has a prescription for a transfusion of packed RBCs
-Administration of blood is a procedure that carries risk; therefore, the client must sign a consent
form prior to the procedure.
B. A client who is being transported for a radiograph of the kidneys, ureters, and bladder
-incorrect: Clients admitted to a hospital sign a general consent form when admitted. This form
gives consent for this diagnostic examination.
C. A client who has a prescription for a tuberculin skin test
-incorrect: Implied consent is given when the client cooperates through actions, such as holding
out an arm to allow the nurse to perform the procedure.
D. A client who has a distended bladder and needs urinary catheterization
-incorrect: Implied consent is given when the client cooperates through actions, such as
positioning himself/herself to allow the nurse to perform the procedure.
5. A nurse is preparing to administer a cleansing enema to a client. Which of the following
actions should the nurse plan to take?
A. Insert the rectal tube 15.2 cm (6 in)
-The nurse should insert the rectal tube 7 to 10 cm (3 to 4 in)
B. Wear sterile gloves to insert the tubing
-The nurse should wear clean (nonsterile) gloves to prevent contamination.
C. Position the client on his left side
-Positioning is an important aspect of administering an enema. Having the client lie on his left
side facilitates the flow of the enema solution into the sigmoid and descending colon.
D. Hold the solution bag 91 cm (36 inch) above the client’s rectum
-The nurse should hold the solution bag 30 cm (12 in) above the client’s rectum for a
low enema and 45 cm (18 in) for a high enema. If the nurse holds the solution bag too high, the
solution might run in too fast, causing discomfort and spasms that make retaining the enema
more difficult.
5. A nurse is caring for a client who has bilateral cats on her hands. Which of the following
actions should the nurse take when assisting the client with feeding?
A. Sit at the bedside when feeding the client
-The nurse should avoid appearing to be in a hurry. Sitting at the bedside provides the client with
the nurse’s full attention during the feeding

B. Order pureed foods
-Without any mouth or throat injuries that make chewing or swallowing difficult, the
client should be served foods of an appropriate variety of textures. Pureed foods are for clients
who cannot chew, have difficulty swallowing, or do not have teeth.
C. Make sure feedings are provided at room temperature
-The nurse should ask the client if the food is the correct temperature
D. Offer the client a drink of fluid after every bite
-If the client is unable to communicate, the nurse should offer the client fluids after
every 3 or 4 mouthfuls. However, there is no indication that this client is unable to communicate.
Therefore, the client should tell the nurse when she would like a drink.
6. A nurse is administering an IM injection to a 5-month-old infant. Which of the following
injection sites should the nurse use?
A. Deltoid
-The nurse can use the deltoid muscle for injecting small volumes of medication for
children 18 months of age or older, but its proximity to several nerves and arteries make it a
riskier choice.
B. Ventrogluteal
-This is a safe site for IM injections for clients older than 7 months.
C. Vastus lateralis
-The nurse should use the vastus lateralis site over the anterior thigh for IM injections for infants
and children.
D. Dorsogluteal
-This site is unsafe to use because of its proximity to the sciatic nerve and the superior
gluteal nerve and artery.
7. A nurse is caring for a client who has major fecal incontinence and reports irritation in the
perianal area. Which of the following actions should the nurse take first?
A. Apply a fecal collection system
-The nurse should apply a fecal collection system to divert the feces away from the
area of skin irritation; however, there is another action the nurse should take first.
B. Apply a barrier cream
-The nurse should apply a barrier cream to decrease skin breakdown in the perianal
area from the feces; however, there is another action the nurse should take first.
C. Cleanse and dry the area
-The nurse should cleanse and dry the perianal area to decrease skin irritation;
however, there is another action the nurse should take first.
D. Check the client’s perineum
-The nurse should apply the nursing process priority-setting framework to plan care and
prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning
with an assessment or data collection. Before the nurse can formulate a plan of action, implement
a nursing intervention, or notify a provider of a change in the client’s status, the nurse must first
collect adequate data from the client. Assessing or collecting additional data will provide the
nurse with knowledge to make an appropriate decision. The priority nursing action is for the
nurse to collect more data by assessing the area of irritation.

9. A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse
should identify that which of the following findings is an indication of infiltration?
A. Redness at the infusion site
-Redness at the infusion site is an indication of phlebitis or infection.
B. Edema at the infusion site
-Edema due to fluid entering subcutaneous tissue is an indication of infiltration.
C. Warmth at the infusion site
-Warmth at the infusion site is an indication of phlebitis or infection.
D. Oozing of blood at the infusion site
-Oozing of blood at the infusion site is an indication that the IV system is not intact.
10. A nurse is caring for a client who reports not sleeping at night, which interferes with her
ability to function during the day. Which of the following interventions should the nurse suggest
to this client?
A. Avoid beverages that contain caffeine
-Caffeine is a stimulant. The nurse should suggest that the client avoid caffeinated beverages.
B. Take a sleep medication regularly at bedtime
-Sleep-promoting medication is a last resort. The nurse should not suggest this type of
medication for the client before recommending other nonpharmacological interventions.
C. Watch television for 30 minutes in bed to relax prior to falling asleep
-Clients should associate going to bed with sleep. Therefore, the client should not get
into bed until she is sleepy.
D. Advise the client to take several naps during the day
-Napping in the daytime can prevent sound sleep at night
11. A nurse is conducting an admission interview with a client. Which of the following pieces of
assessment information should the nurse collect during the introductory phase of the interview?
A. Clients level of comfort and ability to participate in the interview
-The nurse should assess the client’s level of comfort and establish a rapport during the
introductory or orientation phase. The nurse should engage in active listening and present a
relaxed attitude to place the client at ease and encourage client participation. This will assist the
nurse in gaining the necessary data to formulate appropriate nursing diagnoses and outcomes.
B. Previous illnesses and surgeries
-The nurse should assess the client’s health history, including previous illnesses and
surgeries, during the working phase of the interview.
C. Events surrounding the client’s recent illness
-The nurse should assess the client’s health history, including events surrounding the
recent or current illness, during the working phase of the interview.
D. Sociocultural history
-The nurse should assess the client’s sociocultural history during the working phase of
the interview.
12. A nurse is performing an abdominal assessment of a client. Which of the following positions
should the nurse tell the client to assume for this examination?
A. Lithotomy
-The lithotomy position is useful for gynecological examinations.

B. Lateral
-The lateral recumbent, or side-lying position, limits access to the abdomen. This
position is useful when auscultating the heart to detect murmurs.
C. Supine
-The nurse should tell the client to assume the supine position to promote relaxation of the
abdominal muscles. Having the client bend the knees enhances relaxation of the stomach
muscles.
D. Sims
-The Sims’ position limits access to the abdomen. This position is useful for rectal and
vaginal examinations.
13. A nurse is caring for a client who is postoperative following an abdominal surgery. Which of
the following actions should the nurse perform first after discovering the client’s wound has
eviscerated?
A. Cover the incision with a moist sterile dressing
– The nurse should apply the safety and risk-reduction priority-setting framework, which assigns
priority to the factor or situation posing the greatest safety risk to the client. When there are
several risks to client safety, the one posing the greatest threat is the highest priority. The nurse
should use Maslow’s Hierarchy of Needs, the ABC priority-setting framework, and/or nursing
knowledge to identify which risk poses the greatest threat to the client. An open wound increases
the risk of peritonitis, and any exposed organ tissue could dry out. Therefore, covering the
wound with a moist sterile dressing is the first action the nurse should take to protect the client.
B. Have the client lie on his back with his knees flexed
-The nurse should use this position to reduce pressure on the incision. However, the
nurse should take another action first.
C. Call the client’s surgeon
-The nurse should notify the surgeon or direct a colleague to notify the surgeon while
tending to the client’s immediate need. However, the nurse should take another action first.
D. Reassure the client
-The nurse should respond to the client’s emotional needs. However, the nurse should
take another action first.
14. A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of
the following actions should the nurse take first?
A. Give the client a glass of water
-The nurse should provide a glass of water to facilitate swallowing during tube
insertion of the NG tube. However, there is another action the nurse should take first.
B. Assist the client into a sitting position
-The nurse should assist the client into a sitting position to insert the NG tube more
easily and allow gravity to help facilitate the passage of the tube. However, there is another
action the nurse should take first.
C. Explain the procedure to the client
-The nurse should apply the least invasive priority-setting framework when caring for this client,
which assigns priority to nursing interventions that are least invasive to the client, as long as
those interventions do not jeopardize client safety. The nurse should take interventions that are
not invasive to the client before interventions that are invasive. This reduces the number of

organisms introduced into the body, decreasing the number of facility-acquired infections.
Informing the client about the procedure reduces fear and assists in gaining the client’s
cooperation, which is important for NG tube insertion and is the priority nursing intervention.
D. Measure the length of tubing to be inserted
-The nurse should measure the length of the tubing to be inserted to ensure proper tube
placement. However, there is another action the nurse should take first.
15. A nurse is providing discharge teaching to a client who is recovering from lung cancer. The
provider instructed the client that he could resume lower-intensity activities of daily living.
Which of the following activities should the nurse recommend to the client?
A. Sweeping the floor
-sweeping the floor is moderate-intensity activity
B. Shoveling snow
-Shoveling snow is a high-intensity activity
C. Cleaning windows
-Cleaning windows is a moderate-intensity activity
D. Washing dishes
-Washing dishes requires a low level of activity and is appropriate for this client.
16. A nurse is caring for a client who is receiving dextrose 5% in water IV at 150 mL/hr and has
ingested 4 oz of water and ½ pint of milk. What is the total 8-hr fluid intake in milliliters that the
nurse should document for this client? (round to nearest whole number)
-1560
17. A nurse is performing a physical examination of a client. The nurse should use percussion to
evaluate which of the following parts of the client’s body?
A. Heart
-The nurse uses inspection, palpation, and auscultation to evaluate the heart.
B. Lungs
-Percussion creates a vibration that helps the examiner determine the density of the underlying
tissue. The lungs are hollow organs that can produce sounds such as resonance (a hollow sound
over alveoli) or dullness (a dull sound over consolidated areas of the lungs or diaphragm). The
nurse also uses auscultation and palpation when evaluating the lungs.
C. Thyroid gland
-The nurse uses inspection and palpation to evaluate the thyroid gland.
D. Skin
-The nurse uses inspection and palpation to evaluate the skin.
18. A nurse is supervising a newly licensed nurse who is administering a controlled substance.
Which of the following actions by the newly licensed nurse indicates an understanding of the
procedure?
A. Placing an unused portion of the medication in a sharps box
-The nurse should not dispose of an unused portion of a controlled substance in the
sharps container because this action does not maintain safe control of the narcotic.
B. Asking another nurse to observe the disposal of an unused portion of the medication

-The nurse should ask another nurse to witness the disposal of a controlled substance to maintain
safe control of the narcotic.
C. Counting the inventory of the available narcotic after administering the medication
-The nurse should count the inventory of the controlled substance before removing a
dosage to maintain safe control of the narcotic.
D. Ensuring that another nurse signs the control inventory form after disposal of an unused
portion of medication
-Two nurses should sign the control inventory form after the disposal of a portion of a
narcotic to maintain safe control.
19. A nurse is caring for a client who has acute renal failure. Which of the following assessments
provides the most accurate measure of the client’s fluid status?
A. Daily weight
-According to the evidence-based priority-setting framework, daily weight provides important
information about the client’s fluid status. A gain or loss of 1 kg (2.2 lb) indicates a gain or loss
of 1 L of fluid; therefore, weighing the client daily will provide the most accurate fluid status
measurement.
B. Blood Pressure
-While blood pressure can indicate a client’s fluid gain or losses, it is not the most
accurate method of measuring fluid changes.
C. Specific gravity
-Specific gravity reflects the kidney’s ability to concentrate urine. While specific
gravity reflects client’s fluid gains or losses, it is not the most accurate method used to measure
fluid changes.
D. Intake and Output
-Intake and output reflect a client’s fluid status. However, this is not the most accurate
method to measure fluid changes.
20. A nurse in a long-term care facility is admitting a client who is incontinent and smells
strongly of urine. His partner, who has been caring for him at home, is embarrassed and
apologizes for the smell. Which of the following responses should the nurse make?
A. “A lot of clients who are cared for at home have the same problem”
-This automatic response implies that caregivers in the home are not able to keep
client’s odor-free. It is a judgmental statement that is not therapeutic.
B. “Don’t worry about it. He will get a bath, and that will take care of the odor.”
-Telling the partner not to worry blocks communication by devaluing her feelings and
her concern about the odor.
C. “It must be difficult to care for someone who is confined to bed.”
-This response addresses the feelings of the partner by reflecting her feelings, which facilitates
therapeutic communication because it is nonjudgmental and encourages the partner to express
her feelings.
D. “When was the last time that he had a bath?”
-This response implies that the odor of urine has developed because she has not bathed
her husband for some time, which is judgmental and nontherapeutic.

21. A nurse in an emergency department is assessing a client who reports diarrhea and decreased
urination for 4 days. Which of the following actions should the nurse take to assess the client’s
skin turgor?
A. Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to
become pink.
-This technique assesses capillary refill.
B. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs
back.
-The nurse should use this technique to assess skin turgor. If the client has good turgor and is
properly hydrated, the skin will immediately return to normal; in dehydration, the skin will
remain tented. The nurse can also assess turgor by grasping a skinfold on the back of the
forearm.
C. Press the skin above the ankle for 5 seconds, release it, and note the depth of the impression.
-This technique determines the extent of a client’s pitting edema.
D. Measure the skinfold thickness on the upper arm using a pair of calibrated skinfold calipers.
-This technique determines a client’s body fat percentage.
22. A nurse discovers that a client received the wrong medication. Which of the following
actions should the nurse take first?
A. Complete a medication error report
-The nurse should follow the facility’s protocol for documenting the incident;
however, this is not the first action the nurse should take.
B. Notify the prescribing provider
-The nurse should follow the facility’s protocol for reporting a medication error, which
usually involves notifying the prescribing provider; however, this is not the first action the nurse
should take.
C. Assess the client
-The greatest risk to the client’s safety is adverse effects from either receiving the wrong
medication or not receiving the prescribed medication. The nurse should assess the client first for
any possible adverse effects. This assessment also serves as a baseline for further monitoring for
adverse effects.
D. Notify the charge nurse
-The nurse should follow the facility’s protocol for reporting a medication error, which usually
involves notifying the charge nurse; however, this is not the first action the nurse should take.
23. A nurse is performing a breast examination for a female client. Which of the following
techniques should the nurse use first?
A. Inspect both breasts simultaneously
-According to evidence-based practice, the nurse should first inspect both breasts with the
client’s arms in several different positions to look for asymmetry, masses, retraction, lesions,
inflammation, and dimpling.
B. Squeeze the nipples
-The nurse should compress the nipples to identify the presence of any discharge.
However, evidence-based practice indicates that the nurse should use a different technique
before compression.
C. Palpate the breast and tail of Spence

-The nurse should palpate the breast and tail of Spence to determine the consistency of
breast tissue and assess the presence of masses. However, evidence-based practice indicates that
the nurse should use a different technique before palpation of the breast because doing so can
alter the accuracy or effectiveness of another phase of the examination.
D. Palpate the axillary lymph nodes
-The nurse should palpate the axillary lymph nodes, which become involved when
cancerous lesions metastasize. However, evidence-based practice indicates that the nurse should
use a different technique before palpation of the axillary lymph nodes because doing so can alter
the accuracy or effectiveness of another phase of the examination.
24. A nurse is helping a client change his hospital gown. The client has an IV infusion via an
infusion pump. Which of the following actions should the nurse take first?
A. Remove the sleeve of the gown from the arm without the IV line.
-According to evidence-based practice, the nurse should first remove the gown from the client’s
arm without the IV line. Beginning this process will enable the nurse to move the gown fully off
the client before stopping the system to remove the gown from the line, resulting in minimal
interruption of the IV flow.
B. Slow the infusion using a roller clamp
-The nurse should slow the infusion using the roller clamp to prevent a large volume
infusion of IV solution while changing the gown. However, evidence-based practice indicates
that the nurse should take a different action first.
C. Disconnect the IV line from the pump
-The nurse should disconnect the IV line from the pump while removing and
reapplying the gown quickly to maintain the infusion rate prescribed with the pump, however,
evidence-based practice indicates that the nurse should take a different action first.
D. Bring the IV solution and tubing from the outside to the inside of the sleeve of the gown
-The nurse should bring the IV solution and tubing through the outside to the inside of
the sleeve of the gown to avoid tangling of the tubing and the gown. However, evidence-based
practice indicates that the nurse should take a different action first.
25. A nurse is preparing to administer a unit of packed RBC’s to a client when she discovers that
the IV line is no longer patent. The IV team informs her that someone can come to initiate a new
line in 30 min. Which of the following actions should the nurse take?
A. Return the blood to the laboratory
-Because the nurse knows that the delay will be more than a few minutes, she should return the
unit of packed RBCs immediately to the laboratory where the technician will maintain it at the
appropriate temperature until the client is ready to receive it.
B. Place the blood in the medication room
-The unit of packed RBCs should not be at room temperature for any length of time
because the lack of temperature control could damage the blood.
C. Place the blood in the refrigerator
Incorrect: Blood products require specific temperature regulation, which is not consistently
possible in a standard nursing unit refrigerator.
D. Leave the blood at the client’s bedside
-The nurse should never leave blood products or medication at the bedside due to the potential
for loss, misuse, or contamination.

26. A hospice nurse is reviewing religious practices of a group of clients with a newly licensed
nurse. Which of the following statements by the newly licensed nurse indicates an understanding
of the teaching?
A. People who practice the Islamic faith pray over the deceased for a period of 5 days before
burial.
-For those who practice the Islamic faith, the body of the deceased is washed and
wrapped during a ritual and then buried as soon as possible following death.
B. People who practice the Hindu faith bury the deceased with their head facing north.
-People who practice the Hindu faith may place the body with the head facing north
following death. However, cremation rather than burial is practiced by those of the Hindu faith.
C. People who practice Judaism stay with the body of the deceased until burial.
-In the Jewish faith, a family member often stays with the body until burial occurs.
D. People who are practicing the Buddhist faith have the female family members prepare the
body following death.
-Male family members prepare the body following death for individuals practicing the
Buddhist faith.
27. A nurse is planning an in-service training session about nutrition. Which of the following
statements should the nurse include in the teaching?
A. “Fats provide energy”
-Fat serves as a stored energy source for the body, providing 9 cal/g of energy.
B. “Carbohydrates repair body tissue”
-Proteins play a role in tissue repair.
C. “Fats regulate fluid balance”
-Protein is primarily responsible for regulating fluid balance.
D. “Carbohydrates prevent interstitial edema”
-The presence of protein prevents interstitial edema. An appropriate amount of
albumin in blood keeps interstitial edema from occurring.
28. A nurse is caring for a client who requires fluid restriction and may drink only 1 oz of water
with each oral medication. How many milliliters of water should the nurse document as intake
for the 3 separate medications the client receives during 12-hour night shift? (round to the
nearest whole number)
90
29. A nurse is caring for a client who is dehydrated. The nurse should expect that insensible fluid
loss of approximately 500 to 600 mL occurs each day through which of the following organs?
A. Kidney’s
-The kidneys excrete approximately 1,200 to 1,500 mL of urine daily. However, urine
is not considered insensible fluid loss. This can increase depending on the client’s intake of
water.
B. Lungs
-The lungs excrete approximately 400 mL of insensible fluid loss each day.
C. Gastrointestinal Tract

-The GI tract loses approximately 100-200 mL of fluid each day through feces.
However, this is not considered insensible fluid loss.
D. Skin
-The skin can excrete approximately 500 to 600 mL of insensible fluid loss. This type of fluid
loss is continuous and can increase if the client is experiencing a fever or has had a recent burn to
the skin.
30. A nurse is caring for an adult client who communicates an unmet spiritual need. Which of the
following client statements should indicate to the nurse that the client is experiencing spiritual
distress?
A. “Life has its ups and downs”
-This statement suggests the client is experiencing and incorporating a sense of
spiritual wellbeing by accepting life’s ups and downs.
B. “I believe that I control my own destiny”
-This statement suggests the client is experiencing and incorporating a sense of
spiritual wellbeing by being in control of personal destiny.
C. “God is punishing me for something”
-Spiritual distress is an impaired ability to integrate meaning and purpose in life through various
means, including belief systems and relationships. Manifestations of spiritual distress can include
a feeling that a higher power is punishing the individual for some behavior.
D. “I like to keep my rosary beads in bed with me”
-This statement suggests that the client is experiencing and incorporating a sense of
spiritual wellbeing by engaging in prayer activities such as the rosary.
31. While in the hospital, a client who has a terminal illness tells the nurse, “I can’t believe I’m
dying. A lot of bad people in the world are healthy and here I am dying!” Which of the following
responses should the nurse provide?
A. “Everyone dies sometimes; some die sooner than others.”
-This is a nontherapeutic response that dismisses and minimizes the client’s feelings.
B. “Who do you think deserves to die more than you?”
-This is a nontherapeutic response that could be perceived as confrontational by the
client.
C. “It does seem unfair, doesn’t it?”
-While this response acknowledges the client’s feelings, it is a closed-ended statement
that does not facilitate further exploration of the client’s feelings.
D. “Tell me more about how you feel about dying?”
-This therapeutic response from the nurse seeks more information to form an accurate
assessment of the client’s feelings.
32. A nurse is administering medication to a client who asks the nurse to leave the medication at
the bedside to be taken at a later time. Which of the following responses should the nurse make?
A. “Call me when you are ready, and I will return with the medication.”
-The nurse is responsible for administering the medication and for following professional
standards by adhering to the 6 rights of medication administration.
B. “Since you were taking this mediation at home, I will leave it for you to take.”

-At home, the client is responsible and accountable for actions regarding selfadministration of medications. In an inpatient setting, the nurse is responsible for administering
medication to the client.
C. “I will come back in 30 mins to check that you took the medication so I can chart the time.”
-If the nurse returns to the client’s room in 30 minutes, the nurse will not be able to
verify that the client took the medication since the client could have hidden or discarded the
medication.
D. “If you refuse to take the medication now, I can’t give it again until your next scheduled
time.”
-The nurse is responsible for administering the medication at the scheduled time.
Although the policy about time may vary by facility, a medication generally may be given within
1 hour of the prescribed time.
33. A nurse is admitting a client who will undergo a craniotomy. During the planning phase of
the nursing process, which of the following actions should the nurse take?
A. Establish client outcomes
-The planning phase of the nursing process includes developing goals and outcomes that help the
nurse create the client’s plan of care.
B. Collect information about past health problems
-The nurse should collect information about the client’s past health problems during
the assessment phase of the nursing process.
C. Determine whether the client has met specific goals
-The nurse should determine whether the client has met goals during the evaluation
phase of the nursing process.
D. Identify the client’s specific health problems
-The nurse should identify the client’s specific health problems during the analysis
phase of the nursing process.
34. A nurse in a provider’s office is teaching a client about foods that are high in fiber. Which of
the following food choices made by the client indicate an understanding of the teaching? (SATA)
A. Canned peaches
-Canned fruits, including peaches, are recommended for clients on a low-fiber diet.
Fresh fruits contain more fiber.
B. White rice
-White rice is recommended for clients on a low-fiber diet. Brown rice is higher in
fiber.
C. Black beans
-Dried peas and beans, including black beans, are high in fiber.
D. Whole-grain bread
-Whole grains consist of the entire kernel and are also high in fiber.
E. Tomato juice
-Canned juices, with the exception of prune juice, are recommended for clients on a
low-fiber diet.
35. A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe
atelectasis. Which of the following actions should the nurse plan to take?

A. Place the client in the Trendelenburg position
-The nurse should place the client in a right-sided Trendelenburg position to promote drainage
from the client’s left lower lobe.
B. Perform percussions directly over the client’s bare skin
-The nurse should perform percussions over a single layer of clothing.
C. Use a flattened hand to perform percussions
-The nurse should use a cupped hand to provide percussions.
D. Remind the client that chest percussions can cause mild pain
-Chest percussions should not cause pain when the procedure is performed correctly.
36. A middle-aged adult client is discussing future plans with the nurse. Which of the following
statements should the nurse identify as an indication that the client is having difficulty achieving
Erikson’s developmental task for this age group?
A. “We miss our daughter so much that we are going to move closer to her.”
-According the Erikson, the stage of psychosocial development for middle adults is generativity
vs. stagnation. Accepting the independence of adult children is part of the developmental task of
middle age.
B. “I think this year I can plan on managing the funding at church.”
-Middle-aged adults should turn their focus to community and volunteer activities,
according to Erikson’s developmental task of generativity vs. stagnation for this age group.
C. “I really wish I could lose some of this weight.”
-Metabolism slows during middle age, and clients tend to gain unnecessary weight.
Concern about this weight gain is an expected finding.
D. “I find I am spending more time at work now that my son is at college.”
-Middle-aged adults often focus more on work as they try to achieve Erikson’s
developmental task of generativity vs. stagnation.
37. A nurse is caring for a client who is receiving intermittent enteral feedings through an NG
tube. The specific gravity of the client’s urine is 1.035. Which of the following actions should
the nurse take?
A. Deliver the formula at a slower rate
-Slowing the delivery rate is an intervention for diarrhea.
B. Request a lower-fat formula
-Instilling a lower-fat formula is an intervention for abdominal distention and bloating.
C. Provide more water with feedings
-The elevation in the client’s specific gravity indicates dehydration. The nurse should provide
more fluids either by adding free water to feedings or by instilling water between feedings.
Another strategy is to request a formula that contains less protein.
D. Instill a lactose-free formula
-Instilling a lactose-free formula is an intervention for nausea and vomiting.
38. A nurse is assessing a client who has a sudden onset of severe back pain of unknown origin.
Which of the following questions should the nurse ask to encourage discussion with the client?
A. “Does the medication you’re taking relieve the pain?”

-Close-ended statements generally elicit a 1- or 2-word response and is restrictive
when seeking more information. Closed-ended questions are used to obtain information quickly
in an emergency situation.
B. “Can you point to where the pain is the worst?”
-The nurse should use the pain scale or have the client describe the pain to elicit an
open-ended conversation.
C. “What do you think caused the onset of your pain?”
-The nurse is using an open-ended question that allows the client to respond with a wide range of
information by using more than a few words.
D. “Changing positions makes your pain worse, right?”
-Closed-ended questions are used to obtain information quickly in an emergency
situation. The nurse should ask the client to describe which position facilitates the greatest relief
of the pain to elicit an open-ended conversation.
39. A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the
following actions should the nurse direct the client to take first?
A. Aim the hose at the base of the fire
-Evidence-based practice indicates aiming the hose of the fire extinguisher is the
second step the client should take.
B. Squeeze the handle of the extinguisher
-Evidence-based practice indicates squeezing the handle of the extinguisher is the third
step the client should take.
C. Remove the safety pin from the extinguisher
-Evidence-based practice indicates removing the safety pin from the extinguisher is the first
action to take when using a fire extinguisher; therefore, this is an action the nurse should instruct
the client to perform first.
D. Sweep the hose from side to side to dispense material
-Evidence-based practice indicates sweeping the hose from side to side to dispense
material is the fourth step the client should take.
40. A nurse is planning care for a client who is confused and requires a prescription for wrist
restraints. Which of the following interventions should the nurse include in the plan of care?
A. Renew the prescription for the use of restraints within 24 hours
-The nurse should plan to renew the prescription for the restraints within 24 hours; only after the
provider has evaluated the client.
B. Secure the restraint with the buckle side next to the client’s skin
-The nurse should secure the client’s restraints with the softer side next to the client’s
skin with the buckle or Velcro closure on the outside.
C. ensure 4 fingers can be inserted under the secured restraint
-The nurse should ensure 2 fingers can be inserted under the restraints to prevent the
restraint from being too loose. If the nurse is unable to insert 2 fingers under the restraint, it
could cause impaired circulation to the extremities.
D. Remove the restraint every 3 hours
-The nurse should remove the restraint at least every 2 hours; at that time, the nurse
should check the client’s skin, change the client’s position, and toilet or exercise the client.

41. A nurse is caring for a client who has a terminal illness. The client asks several questions
about the nurse’s religious beliefs related to death and dying. Which of the following actions
should the nurse take?
A. Change the topic because the client is trying to divert attention from the illness.
-Changing the subject is a nontherapeutic communication technique that will block the
development of an open exchange between the nurse and the client.
B. Encourage the client to express thoughts about death and dying.
-The nurse should recognize the client’s need to talk about impending death and encourage the
client to discuss thoughts on the subject. This is the therapeutic technique of reflecting.
Depending on the situation, the nurse can also share some thoughts on this topic. Self-disclosure
is a communication skill that can encourage sharing when appropriate. If the nurse does not want
to share personal beliefs, offering self and listening to the client’s thoughts are appropriate.
C. Tell the client that religious beliefs are a personal matter.
-This closed-ended response is a nontherapeutic technique that will block the
communication with this client.
D. Offer to contact the client’s minister or the facility’s chaplain.
-This response disregards the client’s issue and could create barriers to communication
between the nurse and the client.
42. A nurse is caring for a middle-aged adult client. The nurse should identify which of the
following statements as an indication that the client has completed Erikson’s developmental task
for her age group?
A. “I am comfortable with my decision to choose a lifelong partner.”
-This statement relates to Erikson’s developmental task for young adults, which is
intimacy vs. isolation.
B. “I think I have done a good job with my children since they are all independent now.”
-According to Erikson, the developmental task for middle adults is generativity vs. stagnation.
Middle adults help shape future generations through community involvement, parenting,
mentoring, and teaching. This statement about helping her children achieve independence
indicates that the client has accomplished this developmental task.
C. “As I look back over my life, I can see that I have achieved most of the goals I set for
myself.”
-This statement relates to Erikson’s developmental task for older adults, which is
integrity vs. despair.
D. “I love my work so much that it is difficult to think about retirement.”
-This statement relates to Erikson’s developmental task for older adults, which is
integrity vs. despair.
43. A nurse is inserting an NG tube into a client who begins to gag and cough. Which of the
following actions should the nurse take?
A. Remove the NG tube
-The nurse should not remove the NG tube if the client begins to cough and gag
because this can result in increased discomfort for the client.
B. Advance the NG tube quickly
-The nurse should not advance the NG tube while the client is coughing because this
can result in inserting the tube into the client’s trachea.

C. Pull the NG tube back slightly
-The nurse should slightly pull back the NG tube and instruct the client to breathe slowly. Once
the client relaxes, the nurse should gently advance the tube as the client swallows.
D. Ask the client to tilt his head backward
-The nurse should ask the client to tilt his head forward to aid the insertion of the NG
tube into the esophagus.
44. An adolescent client in an outpatient mental health facility tells the nurse that he struggles to
follow his treatment plans because his friends discourage him. Which of the following statements
should the nurse make?
A. “Don’t worry; teenagers often have friends who give bad advice.”
-This response is a barrier to communication. It is a stereotypical response and will not
encourage open communication.
B. “I think you should stop seeing those friends since they discourage you from following your
treatment plan.”
-While the adolescent should possibly stop seeing these friends, sharing personal
advice will probably be rejected by the adolescent and will not encourage open communication.
C. “Tell me more about how your friends discourage you.”
-The nurse should ask an open-ended question that encourages the client to elaborate on these
problems.
D. “Where did you meet these friends?”
-This response changes the subject, which will not encourage open communication.
45. A nurse is teaching a client about the use of a straight-legged cane. Which of the following
client actions indicates an understanding of the teaching?
A. The client holds the cane on the unaffected side.
-The nurse should instruct the client to hold the cane on the unaffected side to provide a wide
base of support and stability.
B. The client walks by stepping with the unaffected leg before the affected leg.
-The nurse should instruct the client to walk by stepping with the affected leg before
the unaffected leg to maintain stability.
C. The client holds the cane directly next to the foot.
-The nurse should instruct the client to place the cane at about 15 cm (6 in) to the side
of the foot to provide balance and support.
D. The client holds the cane with a straight elbow.
-The nurse should instruct the client to hold the cane with the elbow slightly flexed to
provide support and stability.
46. A nurse is preparing to administer sotalol to a client with a prescription for 320 mg/day
divided equally every 12 hr. The medication is available in 80 mg tablets. How many tablets
should the nurse administer per dose? (nearest tenth)
2

47. A nurse is caring for a client who had a mastectomy and has a self-suction drainage
evacuator in place. Which of the following actions should the nurse take to ensure proper
operation of the device?
A. Irrigate the tubing with sterile normal water once during each shift.
-The nurse should keep the diaphragm of the device compressed to maintain suction
and prevent clotting of sanguineous drainage. This drainage system is not made for irrigating.
B. Cleanse the opening with soap and water after emptying.
-The nurse should cleanse the drain opening with an alcohol wipe after opening it to
decrease the entry of microorganisms.
C. Maintain the tubing above the level of the surgical incision.
-The nurse should maintain the drainage tubing below the level of the incision to
enhance drainage.
D. Collapse the device to remove air after emptying.
-The nurse should collapse the device to remove air after emptying the contents periodically.
This will create enough suction to pull fluid exudate into the collection area of the device.
48. A nurse is planning weight-loss strategies for a group of clients who are obese. Which of the
following actions by the nurse will improve the client’s commitment to a long-term goal of
weight loss?
A. Attempt to increase the client’s self-motivation
-Motivation to learn is a key part of improving a client’s commitment to achieving a health goal,
as well as increasing the amount and speed of learning.
B. Keep detailed records of each client’s progress
-This will help each client track individual progress but does not improve client
progress toward individual goals.
C. Test client learning after each teaching session
-Testing learning helps to determine whether outcomes are reached but does not affect
each client’s commitment to the goal.
D. Avoid discussing topics that might increase client’s anxiety
-Anxiety can interfere with learning and should be addressed early in the teaching
process.
49. A nurse is teaching a client how to perform range-of-motion exercises of the wrist. To
perform adduction, which of the following instructions should the nurse include?
A. “With your palm facing down, move your wrist sideways toward your thumb.”
-This motion describes adducting the wrist. The client should be able to move her wrist 30 to 50
degrees with this motion.
B. “Move your palm toward the inner part of your forearm.”
-This motion is flexing the wrist.
C. “With your palm facing down, move your wrist sideways toward your little finger.”
-This motion is abducting the wrist.
D. “Bring the back of your hand as far back toward the wrist as you can.”
-This motion is hyperextending the wrist.

50. A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of
the following results should the nurse identify as an indication that the client has conductive
hearing loss of the left ear?
A. Air conduction is less than bone conduction in the left ear.
-This finding indicates conductive hearing loss of the left ear.
B. Air conduction is greater than bone conduction in the left ear.
-This finding does not indicate hearing loss of any type.
C. Sound is lateralizing to the right ear.
-These are possible results of the Weber test, not the Rinne test.
D. Sound is lateralizing to the left ear.
-These are possible results of the Weber test, not the Rinne test.
51. A nurse is preparing a client who is scheduled for a hysterectomy for transport to the
operating room. The client states she no longer wants to have the surgery. Which of the
following actions should the nurse take?
A. Tell the client it is too late for her to change her mind because the surgery is already
scheduled.
-The client has the right to refuse a procedure after giving consent.
B. Telephone the operating room and cancel the surgery.
-This is not the responsibility of the nurse but a decision the surgeon and the client
must make.
C. Inform the client’s family about the situation.
-To respect the client’s confidentiality, the family can be notified only after the client
requests that the nurse do so.
D. Notify the provider of the client’s decision.
-While acting as the client’s advocate, the nurse should support her decision and notify the
provider.
52. A nurse is admitting a client who has decreased circulation in his left leg. Which of the
following actions should the nurse take first?
A. Evaluate pedal pulses
-For a client who has decreased circulation in the leg, evaluating pedal pulses is critical in order
to determine adequate blood supply to the foot. The nurse should apply the safety and risk
reduction priority-setting framework. This framework assigns priority to the factor posing the
greatest safety risk to the client. When there are several risks to client safety, the one posing the
greatest threat is the highest priority. The nurse should use Maslow’s Hierarchy of Needs, the
ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the
greatest threat to the client.
B. Obtain a medical history
-The nurse should obtain the client’s medical history. However, there is another action
the nurse should take first.
C. Measure vital signs
-The nurse should obtain baseline vital signs. However, there is another action the
nurse should take first.
D. Assess for leg pain

-The nurse should assess the client for pain. However, there is another action the nurse
should take first.
53. A new resident provider asks the charge nurse for an access code to review clients’ online
records. The resident is not scheduled to attend the facility’s orientation computer class until next
week. Which of the following actions should the nurse take?
A. Explain that it is against policy to share access codes and refer the resident to his
supervisor.
– Staff members should never share access codes and passwords or allow people who do not have
their own access code to use the system. Allowing unauthorized access is a breach of federal
guidelines for data security and client confidentiality.
B. Access the clients’ online data and monitor the resident as he reads them.
-Allowing an individual who does not have a personal access code to view the system
is a breach of federal guidelines for data security and client confidentiality.
C. Access the online system and allow the resident to locate clients’ data.
-Allowing an individual to access the system without a personal access code is a
breach of federal guidelines for data security and client confidentiality.
D. Ask each client to give permission for the resident to access medical records.
-The resident should not have access to client information until he participates in the
facility’s training, which includes information about data security and client confidentiality.
Even then, he should only have access to information directly needed to provide care to his
specific clients.
54. A nurse is caring for a client who has injuries resulting from a motor-vehicle crash. Which of
the following client statements should the nurse address first?
A. “I’m afraid this injury will cause me to lose my job.”
-The client’s fear of job loss is associated with the client’s identity and economic
survival. However, this is a self-esteem need; another need is the priority.
B. “I can’t sleep well because whenever I move in my sleep, the pain wakes me up.”
-The priority action the nurse should take when using Maslow’s hierarchy of needs id to meet the
client’s physiological need for comfort. The nurse should re-evaluate the client’s pain
management plan immediately.
C. “I don’t know what I will do if my car isn’t safe or even drivable after the crash.”
-The client’s concern about the vehicle is a safety and security need; however, another
need is the priority.
D. “I wonder how I am going to be able to take care of my family.”
-The client’s need to care for family members in the same way as before is a love and
belonging need; however, another need is the priority.
55. A nurse is preparing a client for discharge and providing instructions about performing
dressing changes at home. Which of the following statements should the nurse identify as an
indication that the client understands medical asepsis?
A. “I’ll wrap the old dressing in a paper bag and put it in the trash.”
-Local regulations for disposal of contaminated items may vary. In general, placing the
old dressing in a plastic bag and sealing it is an acceptable means of disposal in the household
trash.

B. “I’ll wash my hands before I remove the old dressing and again before putting on the
new one.”
-It is essential that the client understands the importance of hand hygiene before, during, and
after any handling of the wound or its dressings.
C. “I’ll need to take a pain pill 30 minutes before I change the dressing.”
-This might be a good practice if the dressing changes are painful; however, this
statement does not address medical asepsis, only pain management.
D. “I’ll wear sterile gloves when I apply the new dressing.”
-Clean gloves and dressings are standard for clients at home. If sterile dressings are
necessary, a home health care nurse should perform the dressing changes.
56. A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the
following statements by the AP indicates an understanding of the teaching?
A. “There are times I should use soap and water rather than an alcohol-based rub to clean
my hands.”
-While alcohol-based hand rubs are as effective as soap and water in providing proper hand
hygiene, the Centers Disease Control and Prevention recommend washing hands with soap and
water at certain times, such as when the hands are visibly soiled with dirt or body fluids.
B. “I will use cold water when I wash my hands to protect my skin from becoming dry.”
-Hand hygiene should be performed with warm water, which preserves the protective
oil of the skin better than hot water.
C. “I will apply friction for at least 10 seconds while washing my hands.”
-Friction is required to loosen and remove dirt and pathogens from the hands. To be
effective, friction should be applied for at least 15 to 20 seconds.
D. “After washing my hands, I will dry them from the elbows down.”
-Drying should be performed from the cleanest area (fingertips) to the least clean area
(forearms) to prevent contamination of the newly cleaned hands.
57. A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a
bed to a wheelchair. Which of the following techniques should the nurse use?
A. Stand toward the client’s stronger side.
-Safely transferring a client from a bed to a wheelchair requires the nurse to stand in
front of the client toward the side that requires the most support. This technique will help
maintain balance during the transfer.
B. Instruct the client to lean backward from the hips.
-Safely transferring a client from a bed to a wheelchair requires the nurse to instruct
the client to lean forward from the hips. This technique positions the client in the proper
direction of the movement.
C. Place the wheelchair at a 45-degree angle to the bed.
-Positioning the wheelchair at a 45-degree angle allows the client to pivot, lessening the amount
of rotation required.
D. Assume a narrow stance with the feet 15 cm (6 in) apart.
-Safely transferring a client from a bed to a wheelchair requires the nurse to assume a
wide stance with one foot in front of the other. This technique protects the nurse from losing
balance during the transfer.

58. A nurse is preparing to provide tracheostomy care for a client. Which of the following
actions should the nurse perform first?
A. Open all sterile supplies and solutions.
-The nurse should open all sterile supplies and solutions prior to providing
tracheostomy care. However, there is another action the nurse should take first.
B. Stabilize the tracheostomy tube.
-the nurse should stabilize the tracheostomy tube to prevent accidental extubation
while providing tracheostomy care. However, there is another action the nurse should take first.
C. Put on sterile gloves
-The nurse should put on sterile gloves prior to providing tracheostomy care to reduce
the transmission of organisms. However, there is another action the nurse should take first.
D. Perform hand hygiene
-According to evidence-based practice, the nurse should first perform hand hygiene before
touching the client or performing any skills, such as tracheostomy care. This is vital because
contamination of the nurse’s hands is a primary source of infection.
59. A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of
stool. Which of the following personal protective equipment (PPE) items should the nurse don
prior to providing client care? (SATA)
A. Gown
-The nurse should follow standard precautions when caring for a client who has AIDS. Because
the bed linens might be soiled, the nurse should don a gown. Because the nurse’s hands will
come in contact with the soiled bed linens, the nurse should don clean gloves in addition to other
necessary PPE.
B. Gloves
-The nurse should follow standard precautions when caring for a client who has AIDS. Because
the bed linens might be soiled, the nurse should don a gown. Because the nurse’s hands will
come in contact with the soiled bed linens, the nurse should don clean gloves in addition to other
necessary PPE.
C. Mask
-AIDS is not transmitted by droplets or inhalation, so a mask is not necessary when
changing the client’s bed linens.
D. Hair cover
-A hair cover is not necessary when changing the client’s bed linens.
E. Goggles
-Goggles are not necessary since the splashing of bodily fluids is unlikely when
changing the client’s bed linens.
60. A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA)
infection. A dietary assistant asks the nurse what precautions are necessary for entering the
client’s room with the lunch tray. Which of the following instructions should the nurse give to
the dietary assistant?
A. Don a gown before entering the room and remove it before exiting
-Anyone who will have actual contact with this client must wear a gown. If the dietary
assistant is just placing the lunch tray on the client’s table, donning a gown is not necessary.
B. Wear a mask while in the client’s room

-MRSA does not spread via droplet or aerosol transmission; therefore, the dietary
assistant does not need to wear a mask.
C. Don gloves when entering the room and use hand sanitizer when exiting
-Clients who have MRSA infection require contact precautions. In addition to the use of standard
precautions and meticulous hand hygiene, contact precautions require any staff member who will
have contact with the client’s environment to don gloves prior to entering the room. Additional
precautions, such as a gown, are required for contact with the client; a mask and goggles are
needed if the secretions from the infected area could spray into the worker’s face. Delivering the
tray will require contact with the client’s environment; therefore, the dietary assistant must wear
gloves.
D. Take no special precautions unless engaging in direct contact with the client
-Infections with multidrug-resistant organisms, such as MRSA, require special
precautions to prevent transmission of the pathogen through contact with the client and the
client’s environment.
61. A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client.
Which of the following actions by the newly licensed nurse requires interventions?
A. Obtaining hydrogen peroxide for tracheostomy care
-A half-strength peroxide solution is used to clean the inner cannula.
B. Obtaining cotton balls for tracheostomy care
-Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing a tracheal
abscess. The charge nurse should intervene for this action.
C. Obtaining sterile gloves for tracheostomy care
-Tracheostomy care is a sterile procedure requiring the use of sterile gloves.
D. Obtaining a sterile brush for tracheostomy care
-Pipe cleaners or a small sterile brush can be used to remove thick or crusty secretions
from the inner cannula.
62. A nurse is providing nutritional teaching to a group of clients. Which of the following
definitions for the recommended dietary allowance (RDA) should the nurse include in the
teaching?
A. The RDA is a comprehensive term that includes various standards and scales.
-Dietary reference intakes (DRIs) include 4 nutrition-based standards that are used to
plan dietary intake and evaluate a client’s nutritional status. These dietary standards include
RDAs, estimated average requirements (EARs), adequate intake (AI), and tolerable upper intake
levels (ULs).
B. The RDA defines the level of nutrient intake that meets the needs of healthy people in
various groups.
-The RDA represents daily requirements considered adequate for healthy people. RDAs are
based on estimated amounts for each nutrient, including additional amounts for individuals such
as women or infants.
C. The RDA defines the levels of nutrients that should not be exceeded to prevent adverse health
effects.
-Tolerable upper intake levels (ULs), not RDAs, are the levels of nutrients that should
not be exceeded to prevent adverse effects.
D. The RDA is the daily percentage of energy intake values for fat, carbohydrate, and protein.

-Acceptable macronutrient distribution ranges (AMDRs) are the daily percentage of energy
intake values for fat, carbohydrate, and protein.
63. A nurse is reviewing a client’s 24 hr dietary recall. The client reports eating a slice of toasted
white bread with butter, a banana, a glass of milk, and a cup of coffee for breakfast; grilled
chicken, a baked potato, and a glass of milk for lunch; an apple and cheddar cheese for a snack;
and 2 servings of chicken, 2 cups of steamed broccoli, and a glass of milk for dinner. This
client’s diet is deficient in which of the following food groups?
A. Dairy
-The client consumed 3 servings of dairy throughout the day, which is the
recommended daily amount according to USDA dietary guidelines.
B. Vegetables
-The client consumed 2.5 cups or more of vegetables, which is the recommended daily
amount according to USDA dietary guidelines.
C. Fruits
-The client consumed 2 servings of fruit, which is the recommended daily amount
according to USDA dietary guidelines.
D. Grains
-This client only consumed 1 serving of grains on the day of the 24-hour dietary recall.
USDA dietary guidelines recommend 3 or more ounce-equivalents of whole-grain products per
day. Additionally, the choice of white bread is low in fiber, which can lead to constipation and an
increased risk of developing hyperlipidemia. The USDA guidelines recommend that at least half
of the grains consumed should be whole grain.
64. A nurse is assessing a client’s pulses of the lower extremities. The nurse should identify
which of the following as the location of the most distal pulse?
A. Popliteal
-The nurse should identify that the popliteal pulse is located behind the knee. It is best
felt with the client’s knee slightly flexed and the foot resting on an examination table.
B. Posterior Tibial
-The nurse should identify that the posterior tibial pulse is located on the inner side of
the ankle. It is best felt with the client’s foot relaxed and extended slightly.
C. Dorsalis Pedis
-The nurse should identify that the dorsalis pedis pulse is located on the top of the foot, following
the groove between the tendons of the great toe. It is best felt by moving the fingertip between
the first and second toe and slowly moving up the dorsum of the foot. However, this pulse is
congenitally absent in some clients.
D. Femoral
-The nurse should identify that the femoral pulse is located in the inguinal area. It is
best felt with the client lying down and the inguinal area exposed.
65. A nurse is screening a client who has an S-shaped spinal column with unequal shoulder
heights. The nurse should identify these findings as manifestations of which of the following
abnormalities?
A. Scoliosis

-The nurse should identify the finding of an S-shaped or C-shaped spinal column and uneven
shoulder or hip heights as manifestations scoliosis.
B. Lordosis
-The nurse should expect a client who has lordosis to exhibit manifestations of an
exaggeration of the anterior convex curvature in the lumbar region of the spine.
C. Torticollis
-The nurse should expect a client who has torticollis to exhibit manifestations of the
head inclining toward the affected side with a contraction of the sternocleidomastoid muscle.
D. Kyphosis
-The nurse should expect a client who has kyphosis to exhibit manifestations of an
increased convex curvature in the thoracic region of the spine.
66. A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a
regular-sized cuff for a client who is obese. Which of the following explanations should the
nurse give the AP?
A. “The reading will be inaudible if the cuff is too small for the client.”
-Although the blood pressure reading for a client who is obese may be difficult to hear
with any cuff, a cuff that is too small for the client will not yield an inaudible reading.
B. “The width of the cuff bladder should be 75% of the circumference of the client’s arm.”
-The width of the cuff bladder should be 40% of the circumference of the client’s arm.
C. “As long as the cuff will circle the arm, the reading will be accurate.”
-A cuff that is an incorrect size for the client will not yield an accurate reading.
D. “Using a cuff that is too small will result in an inaccurately high reading.”
-Blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a
reliable measurement. Blood pressure readings can be falsely high if the cuff Is too small for the
client.
67. A home health nurse is planning to provide health promotion activities for a group of clients
in the community. Which of the following activities is an example of primary prevention?
A. Teaching clients to perform self-examinations of breasts and testicles
-This activity is an example of secondary prevention, which focuses on measures that
identify the early stages of a condition.
B. Educating clients about the recommended immunization schedule for adults
-Primary prevention includes health education about disease prevention.
C. Teaching clients who have type 1 diabetes mellitus about care of the feet
-This activity is an example of tertiary prevention, which occurs after diagnosis of a condition
and focuses on limiting complications from the condition.
D. Recommending that clients over the age of 50 have a fecal occult blood test annually
-This activity is an example of secondary prevention, which focuses on measures that
identify the early stages of a condition.
68. A nurse is performing an admission assessment for a client who has asthma and reports
several food allergies. Which of the following actions should the nurse take first?
A. Document the client’s food allergies in the medical record

-The nurse should document the client’s food allergies in the medical record to
communicate this information to other members of the health care team; however, there is
another action that the nurse should perform first.
B. Ask the client to identify the specific food allergies
-The nurse should apply the nursing process priority-setting framework in order to plan client
care and prioritize nursing actions. Each step of the nursing process builds on the previous step,
beginning with an assessment or data collection. Before the nurse can formulate a plan of action,
implement a nursing intervention, or notify the provider of a change in the client’s status, the
nurse must first collect adequate data from the client. Assessing or collecting additional data will
provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse
should first assess the client’s allergies and identify the specific allergens to ensure the specific
foods are not offered to the client during meals.
C. Monitor the client for indications of anaphylaxis
-The nurse should monitor the client for indications of anaphylaxis due to allergen
exposure; however, there is another action that the nurse should perform first.
D. Have epinephrine available for administration
-The nurse should have epinephrine available for administration to treat the
manifestations of an allergic reaction; however, there is another action that the nurse should
perform first.
69. A nurse is evaluating the development of a group of clients. According to Erikson, the
developmental task of intimacy vs. isolation occurs during which of the following stages of
development?
A. Middle adulthood
-The developmental task of middle adulthood is generativity vs. self-absorption and
stagnation.
B. Adolescence
-The developmental task of adolescence is identity vs. role confusion.
C. Childhood
-The developmental task of school-age children is industry vs. inferiority.
D. Young adulthood
-The developmental task of young adulthood is intimacy vs. isolation.
70. A nurse is caring for a client who has cancer and refuses visitors because of his debilitated
physical appearance. Which of the following comments should the nurse make?
A. “You look just fine to me”
-This statement is nontherapeutic and dismisses the client’s concerns.
B. “Nobody expects you to look beautiful in the hospital”
-This response is nontherapeutic and dismisses the client’s concerns.
C. “I understand how you feel. I would feel the same way.”
-This statement is nontherapeutic and focuses on the nurse’s feelings rather than the
clients.
D. “Would you like to talk about how you feel?”
-This is a therapeutic response that will encourage the client to talk about his concerns and
feelings.

71. A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian
cancer. Which of the following statements by the client indicates she is experiencing
psychological distress?
A. “My parents are retired, and they have come to help with our children.”
-Clients who have social and emotional support systems tend to experience less
psychological distress.
B. “I am going to ask my husband to go to counseling with me.”
-Open communication is an important method to improve relationships that might be
strained. Seeking counseling is a positive strategy.
C. “I keep having nightmares about my upcoming surgery.”
-Nightmares and sleep disturbances are manifestations of anxiety and post-traumatic stress
disorder. These indicate a risk of experiencing psychological distress.
D. “My girlfriends bought me a nice wig.”
–Clients who have social and emotional support systems tend to experience less
psychological distress.
72. A nurse is caring for a client who has a terminal illness. The family wants to care for the
client at home. Which of the following statements indicates that the nurse understands familycentered care?
A. “Social services can contact various community resources that will be helpful.”
-In family-centered care, the family and client are the focus; therefore, the family
members must decide, with the input of the health care team, which community resources to
contact. The nurse should still make suggestions and offer support.
B. “I will review the care plan to make the necessary changes.”
-In family-centered care, the family and client are the focus. The nurse should provide
suggestions and offer support but should not make the final decision about changes to the care
plan.
C. “Let’s set up a meeting time with the doctor to discuss your options for home care.”
-In family-centered care, the nurse considers the health of the family as a unit; therefore, the
client and family members help determine their outcomes and goals. Setting up a meeting to
discuss this with the provider will give them a sense of autonomy and foster the family-centered
nursing environment.
D. “I will make a list of things we need to do before discharge.”
-In family-centered care, the family and client are the focus; therefore, the family must
decide, with the nurse’s input, what to do before the client goes home.
73. A nurse is caring for a group of clients in a long-term care facility. One of the clients is
walking along the hallway and bumping into walls and does not respond to his name. Which of
the following actions should the nurse take first?
A. Offer the client a nutritious snack
-The client is at risk of inadequate nutrition because of the fluid and calorie
expenditure from wandering; however, there is another action that the nurse should take first.
B. Accompany the client back to his room
-The nurse should apply the safety and risk-reduction priority-setting framework, which assigns
priority to the factor or situation posing the greatest safety risk to the client. When there are
several risks to client safety, the one posing the greatest threat is the highest priority. The nurse

should use Maslow’s hierarchy of needs, the ABC priority-setting framework, and/or nursing
knowledge to identify which risk poses the greatest threat to the client. Therefore, the nurse
should first escort the client back to his room to protect him from injury due to wandering.
C. Reorient the client to his surroundings
-The client is at risk of anxiety because of possible disorientation; however, there is
another action that the nurse should take first.
D. Administer a PRN antianxiety medication
-The client is at risk of anxiety because of possible disorientation; however, there is
another action that the nurse should take first.
74. A nurse on a medical unit is caring for a client who has difficulty sleeping. Which of the
following actions should the nurse take to promote the client’s ability to fall asleep?
A. Encourage the client to ambulate in the hallway just before bedtime
-Clients should avoid exercising for 2-3 hours before bedtime.
B. Allow the client to maintain the same bedtime routine as at home
-For many clients in an acute care facility, disrupting the usual sleep routine is the primary
reason for a client’s inability to sleep. Maintaining the home bedtime routine promotes sleep in
ways that are effective for the client. Those whose usual bedtime routines include warm milk,
massages, or pharmacological sleep aids might need and appreciate those interventions in
inpatient settings.
C. Keep the room temperature warm
-A cool room temperature is generally more conducive to sleep.
D. Offer the client a cup of hot chocolate before bedtime
-Although the warm milk in hot cocoa or hot chocolate can promote sleep, the
chocolate contains caffeine, which is stimulant and can keep the client awake.
75. A nurse is caring for a client who has cancer and is experiencing pain. The nurse should
implement which of the following interventions to assist the client with pain relief?
A. Encourage the client to listen to soft music
-The nurse should encourage the client to use music therapy to reduce anxiety, provide a
distraction, and relieve pain.
B. Instruct the client to practice tai chi
-The nurse should instruct the client to practice tai chi to stimulate the immune system
and to improve joint function and mobility. However, it is not effective for pain management.
C. Place a jasmine-scented air freshener in the client’s room
-The nurse can use aromatherapy to promote the client’s comfort and healing.
However, jasmine is used to. Improve mood and is not effective for pain management.
D. Offer the client ginger tea
-The nurse should offer the client ginger tea, if it is not contraindicated, to reduce
nausea. However, it is not effective for pain management.
76. A nurse is planning care for a client who has a wound infection following abdominal surgery.
To promote healing and fight infection, which of the following vitamins and minerals should the
nurse plan to increase in the client’s diet?
A. Vitamin C and zinc

-The client’s body needs both vitamin C and zinc to fight a wound infection. The client should
receive a multivitamin and a mineral supplement of both these substances. In addition, vitamin E
supplements also are needed to promote skin and wound healing.
B. Vitamin D
-Vitamin D is used with calcium to prevent osteoporosis; however, it does not assist
with wound healing. The main function of vitamin D is to maintain calcium and phosphorus
levels in the blood, and it may protect against cancer.
C. Vitamin K and iron
-Vitamin K is important for normal blood clotting and for impaired intestinal synthesis
caused by antibiotics. Iron is needed to rebuild RBC’s; however, neither is needed directly for
wound healing.
D. Calcium
-Calcium is administered to prevent osteoporosis when used with vitamin D; however,
it does not aid wound healing.
77. A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the
following actions should the nurse take?
A. Leave the bag in place for 45 mins
-To reduce the risk of injury to the client’s skin, the nurse should leave the ice bag ion
place for no longer than 30 mins.
B. Fill the bag 2/3 full with ice
-The nurse should fill the bag 2/3 full with ice, which allows the bag to be molded around the
clients ankle.
C. Place the ice bag uncovered on the client’s ankle
-The nurse should cover the ice bag with a towel or other type of cover before placing
the ice bag on the client’s ankle to prevent injury to the client’s skin.
D. Tell the client numbness is expected when the ice bag is in place
-The nurse should remove the ice bag if the client feels numbness since this is an
indication that the client’s skin is too cold and at risk for injury.
78. A nurse is caring for a client who has a terminal illness. The client is restless and reports
severe pain but refuses the prescribed opioid pain medication. Which of the following actions
should the nurse take first?
A. Ask why the client is refusing the pain medication
-Using the nursing process, the nurse should first assess the reason for the client’s refusal of the
opioid pain medication.
B. Administer a PRN antianxiety medication
-The nurse should administer a PRN antianxiety medication if it is indicated to
complement other pain management interventions; however, there is another action the nurse
should take first.
C. Help the client change positions
-The nurse should help the client change positions to complement other pain
management interventions; however, there is another action the nurse should take first.
D. Offer the client a heat or cold pack to place on painful areas
-The nurse should offer the client a heat or cold pack to complement other pain
management interventions; however, there is another action the nurse should take first.

79. A nurse is monitoring a client’s fluid intake. For breakfast, the client consumed 8 oz of milk,
10 oz of water, 4 oz of flavored gelatin, 1 scrambled egg, 1 crisp piece of bacon, and 2 biscuits
with jelly. How many mL should the nurse record as the client’s fluid intake? (Nearest whole
number)
-660 mL
80. A nurse is teaching ROM exercises to a client who has osteoarthritis. Which of the following
client positions demonstrates an understanding of supination of the hand?
A. The client holds the hand with the palm up
-The nurse should identify the client holding the hand with the palm up as a demonstration of
supination of the hand
B. The client holds the hand with the palm down
-Holding the hand with the palm down is a demonstration of pronation of the hand.
C. The client points the fingers toward the floor
-Pointing the fingers toward the floor is a demonstration of flexion of the hand.
D. The client points the fingers toward the ceiling
-Pointing the fingers toward the ceiling is a demonstration of extension of the hand.
81. A nurse has received a prescription for dextran to administer to a client. The nurse should
recognize that dextran belongs in which of the following functional classifications?
A. Skeletal muscle relaxants
-Dextran is not a skeletal muscle relaxant. Examples of skeletal muscle relaxants are
cyclobenzaprine and metaxalone.
B. Beta-adrenergic blockers
-Dextran is not a beta-adrenergic blocker. Example of beta-adrenergic blockers are
propranolol and carvedilol.
C. Broad-spectrum anti-infective agents
-Dextran is not a broad-spectrum anti-infective agent. Examples of broad-spectrum
anti-infective agents include ampicillin and cefixime.
D. Plasma volume expanders
-Dextran and albumin are plasma volume expanders that help correct hypovolemia in emergency
situations, such as after hemorrhage or burns.
82. A nurse is preparing to administer liquid medication from a bottle to a client. Which of the
following actions should the nurse take first?
A. Hold the medication bottle with the label against the palm of the hand when pouring
-The nurse should hold a multidose bottle with the label against the palm of the hand when
pouring to prevent contaminating the label with spilled medication that could cause information
on the label to fade or become illegible.
B. Place the cap with the inside facing down on a hard surface
-The nurse should remove the cap of the medication bottle and place it with the inside
facing up on a hard surface to prevent contamination of the inside of the cap and to maintain
cleanliness.
C. Fill the cup until the medication is even with the edge of the dosage scale

-The nurse should fill the cup until the medication is even with the surface or meniscus
base of the dosage scale to ensure the client receives an accurate dose.
D. Pour any excess liquid back into the bottle after measuring
-The nurse should discard any excess liquid medication into the sink as wasted
medication and wipe the lip of the bottle clean after measuring.
83. A nurse is teaching a client who is using a patient-controlled analgesia (PCA) pump to
deliver morphine for pain management. Which of the following statements should the nurse
identify as an indication that the client understands the instructions?
A. “I’ll limit pushing the button, so I don’t get an overdose.”
-PCA devices have a timing control or lockout mechanism that allows a preset
minimum interval between medication doses and limits the total dose per hour. This safety
feature prevents analgesic overdosing.
B. “If I push the button and still have pain after 2 mins, I’ll push it again.”
-PCA devices have a timing control or lockout mechanism that usually allows dosing
every 6 to 8 minutes. If the client pushes the button after 2 mins, the pump will not deliver any
medication.
C. “I’ll ask my niece to push the button when I am sleeping.”
-The client is the only one who should operate the PCA pump. When someone else
operates the pump, it bypasses a safety feature that requires the client to be awake and to decide
whether more medication is needed.
D. “I can still use my transcutaneous electrical nerve stimulation unit while I’m pushing
the PCA button.”
-The nurse should encourage the client to utilize nonpharmacological methods of pain
management such as transcutaneous electrical nerve stimulation (TENS) while using a PCA
pump to reduce the amount of opioid dosing the client needs.
84. A nurse is caring for a semiconscious client who had a small-bore NG tube placed yesterday
for the administration of enteral feeding. Which of the following methods should the nurse use to
verify correct tube placement? (SATA)
A. Auscultate injected air
-Auscultating air injected into an NG tube is not a reliable method of determining
correct NG tube placement.
B. Verify the initial X-Ray examination
C. Measure the length of the exposed tube
D. Determine the pH of aspirated fluid
-The nurse should confirm the NG tube placement by checking the X-ray results following the
insertion of the NG tube. In addition, the nurse should check the length of the NG tube that is
exposed by comparing the markings on the tube to the client’s nose to verify tube placement.
E. Check the aspirated fluid for glucose
-Checking for glucose in the aspirated fluid is not a reliable method of determining
correct NG tube placement.
85. A nurse is preparing to insert an NG tube for a client. Which of the following actions will
help facilitate the insertion of the tube? (SATA)
A. coat the tip of the tube with a water-soluble lubricant
B. Ask the client to swallow water while the tube enters her throat

-Lubricating the tube eases its passage. A water-based gel because it will dissolve if the tube
slips into the client’s airway, while using petroleum jelly could cause respiratory problems.
Swallowing water reduces the risk of gagging and aspiration and helps propel the tube down the
esophagus. Hyperextending the neck reduces the curvature of the nasopharynx, which facilitates
the insertion of the NG tube.
C. Place the coiled tube in ice chips prior to insertion
-Ice makes NG tubes rigid, increasing the risk of trauma to mucous membranes.
D. Tell the client to tilt her head backward as insertion begins
-Lubricating the tube eases its passage. A water-based gel because it will dissolve if the tube
slips into the client’s airway, while using petroleum jelly could cause respiratory problems.
Swallowing water reduces the risk of gagging and aspiration and helps propel the tube down the
esophagus. Hyperextending the neck reduces the curvature of the nasopharynx, which facilitates
the insertion of the NG tube.
E. Instruct the client to bear down during insertion
-Bearing down is helpful during the insertion of a urinary catheter, not an NG tube.
86. A nurse is providing teaching to a group of unit nurses about wound healing by secondary
intention. Which of the following pieces of information should the nurse include in the teaching?
A. The wound edges are well-approximated
-Primary intention involves the closing of the wound using sutures or staples at the
time the incision is made; the suture line edges become well-approximated during healing.
B. The wound is closed at a later date
-Tertiary intention includes using sutures to close an open wound at a later date after
the wound drains and starts to heal.
C. A skin graft is placed over the wound bed
-Tertiary intention can include the provider placing grafted skin over the client’s
wound bed after a wound is left open to drain and start healing. Skin grafting is required for
deeper wounds such as full-thickness burns and is only rarely required for surgical wounds that
do not heal.
D. Granulation tissue fills the wound during healing
-A beefy, red tissue called granulation tissue fills the wound during healing. The wound is left
open to drain and heal by secondary intention, which should occur within 5-21 days. Open
wounds increase the risk of wound infection.
87. A nurse is caring for a client who is receiving IV fluid replacement. Which of the following
findings should the nurse identify as infiltration of the IV infusion site?
A. Redness at the IV catheter entry site
-A client who has redness at the IV catheter entry site might have a local infection. The
nurse should remove the IV, clean the site with alcohol, and start a new IV line in another
location.
B. Palpable cord along the vein used for the infusion
-A client who has a palpable cord along the vein might have phlebitis, which is
inflammation of the inner layer of a vein. The nurse should discontinue the infusion and start a
new IV line in another location.
C. Taut skin around the IV catheter site that is cool to the touch

-A client who has taut skin around the IV catheter site that is cool to the touch might have an
infiltrated IV site. The nurse should stop the IV infusion, elevate the extremity, and apply a
warm moist compress or a cold compress (according to the type of infiltration).
D. Bleeding at the IV insertion site
-Bleeding at the IV insertion site might indicate the IV system is not intact. The nurse should
check to determine if the IV system is intact and if the catheter is within the client’s vein. The
nurse might need to start a new IV line in another location if the bleeding does not stop after
interventions.
88. A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric
decompression. Which of the following actions should the nurse include in the plan of care?
(SATA)
A. Set the suction machine at 120 mmHg
-Single-lumen NG tubes are used for intermittent suction, and the machine is set at 80
to 100 mmHg. Higher suction settings can traumatize the gastric lining.
B. Provide oral hygiene frequently
C. Measure the amount of drainage from the NG tube every shift
D. Secure the NG tube to the client’s gown
-Frequent oral hygiene comfort for the client since mucous membranes become dry and
uncomfortable when a client cannot drink fluids. Measuring the drainage at least every shift
helps the provider calculate fluid loss and prescribe appropriate replacement therapy. An
unsecured NG tube can irritate the nares if the tube is pulled or caught on the bed or other
equipment. The tube can also be dislodged if not secured appropriately.
E. Apply petroleum jelly to the client’s nares
-The client could aspirate an oil-based lubricant like petroleum jelly into the lungs,
which could result in lipid pneumonia. A water-soluble lubricant should be applied to the nares
to help prevent or relieve dry skin.
89. A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which
of the following actions should the nurse take?
A. Maintain suction while removing the NG tube
-The nurse should disconnect the NG tube from the suction apparatus before removal
to decrease the risk of injury to the gastrointestinal mucosa.
B. Instill 100 mL of air into the NG tube before removal
-The nurse should instill 50 mL of air into the tube to clear the contents of gastric
drainage and decrease the risk of aspiration on removal of the tube.
C. Pinch the NG tube while removing the tube
-The nurse should pinch the NG tube while removing the tube to decrease the risk of aspiration
of any gastric contents.
D. Instruct the client to breathe in and out during the removal of the NG tube
-The nurse should instruct the client to take and hold a deep breath during the removal
of the NG tube to close the glottis and decrease the risk of aspiration of any gastric contents.
90. A nurse is planning care for a client who has a prescription for collection of a sputum
specimen for culture and sensitivity. Which of the following actions should the nurse take when
obtaining the specimen?

A. Collect the specimen when the client rises in the morning
-The nurse should plan to collect the sputum specimen when the client arises in the morning
because the client will be able to cough up the secretions that have accumulated during the night.
Generally, the deepest specimens are obtained in the early morning, and it is preferable to collect
the specimen before breakfast. The nurse should instruct the client to rinse the mouth, take a
deep breath, and cough prior to expectorating into the sterile container.
B. Force fluids during the day and collect the specimen in the evening
-The nurse should encourage the client to force fluids, especially clear liquids, to help
thin respiratory secretions. However, evening hours are not the preferred time for obtaining deep
sputum specimens.
C. Collect the specimen after antibiotics have been started
-The nurse should collect the sputum specimen ordered for culture and sensitivity
before the client receives antibiotic therapy to prevent interference with the laboratory results.
D. Collect 2 mL of sputum before sending the specimen to the laboratory
-The nurse should collect 4-10 mL of sputum before sending the specimen to the
laboratory to provide an adequate amount of sputum for culture and sensitivity.
91. After assessing a client, the nurse documents “1+ pedal edema bilaterally.” This indicates
that the nurse observed an indentation of which of the following depths after applying pressure?
A. 2mm
-The nurse should document a 2mm indentation after applying and removing pressure as 1+
pedal edema.
B. 4mm
-The nurse should document a 4mm indentation after applying and removing pressure
as 2+ pedal edema.
C. 6mm
-The nurse should document a 6mm indentation after applying and removing pressure
as 3+ pedal edema.
D. 8mm
-The nurse should document an 8mm indentation after applying and removing pressure
as 4+ pedal edema.
92. A nurse is caring for an adult client who has an NG tube in place and a prescription for
continuous enteral feedings. Which of the following actions should the nurse perform to reduce
the client’s risk of aspiration?
A. Irrigate the tubing with 30 mL of sterile water
-Irrigating the tubing will not reduce the client’s risk of aspiration. Irrigation can help
prevent or resolve clogging of the tube.
B. Elevate the head of the bed to 30 or 40 degrees
-Elevating the head of the bed to at least 30 and preferably 45 degrees helps prevent the
gravitational reflux of gastric contents, thereby decreasing the risk of aspiration.
C. Suggest changing the feeding to lactose-free formula
-Changing the feeding to lactose-free formula will not decrease the client’s risk of
aspiration. It will reduce gastrointestinal irritation or upset in clients who are sensitive to lactose.
D. Warm the enteral formula to room temperature before feeding

-Warming the enteral formula before feeding will not decrease the client’s risk of
aspiration. It can help reduce abdominal cramping and discomfort from cold formula ingestion.
93. A nurse is caring for a client who requires a dressing change. Which of the following actions
should the nurse take?
A. Clean the incision from bottom to top
-The nurse should clean the incision from top to bottom to prevent any contamination
of the area that has already been cleansed. The top of an incision is cleaner because drainage
tends to collect at the bottom of the wound.
B. Apply sterile gloves prior to opening dressing packages
-The nurse should apply sterile gloves after opening dressing packages. To open the
packages, the nurse must touch the nonsterile outside packaging of the sterile supplies. If the
nurse donned the sterile gloves prior to opening the packages, opening the package would
contaminate the gloves.
C. Remove the tape by pulling away from the wound
-The nurse should pull the tape toward the wound to avoid straining the wound and its
sutures, which could lead to dehiscence.
D. Clean the drain site from the center outward
-The nurse should clean the drain site from the center outward to avoid introducing
microorganisms from the periphery of the wound into the center of the wound.
94. A nurse is planning care for a group of clients receiving oxygen therapy. Which of the
following clients should the nurse plan to see first?
A. A client who has heart failure and is receiving 100% oxygen via partial rebreather mask
-The nurse should apply the safety and risk-reduction priority-setting framework, which assigns
priority to the factor or situation posing the greatest safety risk to the client. When there are
several risks to client safety, the one posing the greatest threat is the highest priority. The nurse
should use Maslow’s hierarchy of needs, the ABC priority-setting framework, and/or nursing
knowledge to identify which risk poses the greatest threat to the client.
-The nurse should frequently check the bag on a rebreather mask to ensure it inflates properly. If
the bag is deflated, the client will rebreathe exhaled carbon dioxide instead of receiving the
prescribed oxygen dose. Therefore, the nurse should first see the client who that can cause
toxicity and is highly combustible, and higher concentrations of oxygen increase the risk of
client injury.
B. A client who has emphysema and is receiving oxygen at 3L/min via transtracheal oxygen
cannula
-Routine treatment for chronic lung conditions can include the use of a transtracheal
oxygen cannula; therefore, there is another client the nurse should plan to see first. The client
will learn to use the device alone, and the system can provide adequate oxygenation with a low
flow rate of oxygen. Three liters per minute of oxygen is the equivalent of 32% oxygen delivery.
C. A client who has an old tracheostomy and is receiving 40% humidified oxygen via
tracheostomy collar
-Routine treatment for a client who has an old tracheostomy includes the
administration of humidified oxygen or air via tracheostomy collar. Therefore, there is another
client the nurse should plan to see first. The nurse should sue the humidification to promote

loosening of respiratory secretions and prevent cannula obstruction. Forty percent oxygen is the
equivalent of administering oxygen at 6L/min.
D. A client who has COPD and is receiving oxygen at 2L/min via nasal cannula
-Routine treatment for a client who has COPD involves the administration of low-dose
therapy. Therefore, there is another client the nurse should plan to see first. Clients who have
COPD depend on low oxygen level to drive their respiratory rate. Two liters per minute of
oxygen is the equivalent of 28% oxygen delivery.
95. A nurse is assisting a client who is eating at mealtime. Suddenly, the client grabs her neck
with both hands and appears frightened. Which of the following actions should the nurse take
first?
A. Place an oxygen mask on the client
B. Check the client’s pulses
C. Determine whether the client is able to breathe
-Caring for this client requires the application of the nursing process priority-setting framework.
The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step
of the nursing process builds on the previous step, beginning with an assessment or data
collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or
notify a provider of a change in the client’s status, the nurse must first collect adequate data from
the client. Assessing or collecting additional data will provide the nurse with the knowledge
needed to make an appropriate decision.
-This client is demonstrating a universal choking gesture. If the client is unable to move air in or
out, severe airway obstruction is present. The client would need emergency interventions to clear
a partial obstruction, as indicated by stridor or minimal airway passage. As long as there is good
air exchange and the client can cough and breathe spontaneously, the nurse should stay with the
client and monitor her condition.
D. Wrap arms around the client from behind
-The nurse should wrap arms around the client from behind to perform an abdominal
thrust if breathing is obstructed. However, there is another action the nurse should take first.
96. A nurse is caring for an older adult client who has dysphagia following a cerebrovascular
accident. Which of the following actions should the nurse take when assisting the client at
mealtime?
A. Encourage the client to drink fluids before swallowing food
-A client who has impaired pharyngeal swallowing is at risk of choking when liquids
(especially thin fluids) are offered while eating solid foods. It is preferable to suggest “dry
swallows” to clear the mouth between bites of food.
B. Offer the client tart or sour foods first
-A client who has impaired pharyngeal swallowing should consume tart and sour foods at the
beginning of the meal to stimulate saliva production, which aids to chewing and swallowing.
C. Tilt the client’s head backward when swallowing
-A client who has impaired pharyngeal swallowing should tilt the head forward to
promote swallowing.
D. Turn on the television

-A client who has impaired pharyngeal swallowing should minimize distractions at
mealtimes to concentrate on chewing thoroughly and swallowing.
97. A nurse is caring for a client who reports feeling a pop after coughing without properly
splinting an abdominal incision. On assessment, the nurse notes that the client’s wound has
eviscerated. Which of the following actions should the nurse take? (SATA)
A. Carefully reinsert the intestine through the opening in the wound
-The nurse should not attempt to reinsert the intestine into the client’s abdominal
cavity because this action can cause perforation of the intestine. The nurse should plan to transfer
the client to surgery, where the surgeon will reinsert the intestine under sterile technique.
B. Place the client in a supine position with the hips and knees flexed
C. Leave the room to call the surgeon
-The nurse should delegate another person to notify the surgeon immediately. The
nurse should stay with the client and observe for further complications such as shock.
D. Cover the wound and intestine with a sterile, moistened dressing
E. Monitor the client for manifestations of shock
-The nurse should place the client in a supine position with the hips and knees flexed. This
position can help to prevent further tearing of the incision and wound evisceration by lessening
tension on the wound. The nurse should cover the protruding intestine with sterile dressing that is
moistened with 0.9% sodium chloride to prevent further contamination of the wound and to keep
the protruding intestine from drying out.
-The nurse should monitor the client for a physiological stimulus (ex: bleeding from the tearing
or opening of the wound) or a psychological stimulus (ex: viewing the intestine protruding
outside the body), which can increase the risk of shock. The nurse should monitor the client for
increased heart rate and respiratory rate, changes in blood pressure or mentation and cool or
clammy skin.
98. A nurse documents the presence of clubbing of the fingernails for a client who has
emphysema. Which of the following is the underlying cause of this finding?
A. Trauma
-Trauma does not cause clubbing of the fingernails. Trauma can cause Beau’s lines,
which are another type of nail alteration that involves transverse depressions in the nail. Trauma
can also cause paronychia, an inflammation of the skin at the base of the nail.
B. Severe infection
-Severe infection does not cause clubbing of the fingernails but can cause Beau’s lines.
C. Iron-deficiency anemia
-Iron-deficiency anemia does not cause clubbing of the fingernails. Iron-deficiency
anemia can cause koilonychia (spoon nail), which is another type of nail alteration that involves
concave curves in the nail.
D. Chronic hypoxemia
-Clubbing of the nails of the fingers and toes is the result of chronic hypoxemia (low oxygen
supply) such as COPD. It is a change in the angle between the nail and the nail base often with
enlargement of the fingertips.

99. A nurse delegates the collection of a client’s temperature to an AP. The nurse notes in the
documentation that the AP obtained the client’s axillary temperature; however, the nurse wanted
an oral temperature. The nurse should identify that which of the following rights of delegation
should have prevented this situation from occurring?
A. Right task
-The nurse delegated the right task. The nurse can delegate a task to an AP that is
repetitive, requires minimal supervision, is relatively noninvasive, has predictable results and has
minimal potential for risk. Obtaining a client’s temperature is within the range of function for an
AP.
B. Right circumstance
-The nurse correctly delegated the task in the right circumstance. This entails
consideration of the appropriate client setting, the available resources, and other factors relevant
to the situation.
C. Right person
-The nurse delegated the taking of a client’s temperature to the right person. This
entails delegating the right task to the right person to be performed on the right person. Obtaining
a client’s temperature is within the range of function for an AP and the client’s temperature was
recorded as collected.
D. Right communication
-The situation could have been avoided if the right communication was given by the nurse to the
AP. The right communication entails providing clear, concise instructions regarding the task,
including the objectives, limits, and expectations.
100. A nurse in a long-term care facility is in the dining room while residents are eating lunch.
One resident begins to choke and is coughing strongly. Which of the following actions should
the nurse take?
A. Assist the client to the floor
-The nurse should assist the client to the floor if the client is losing consciousness and
might fall to the floor.
B. Perform an abdominal pain
-The nurse should perform an abdominal thrust if the client is choking and unable to
speak or cough strongly.
C. Open the airway with a head-chin tilt
-The nurse should open the airway with a head-chin tilt to look for a foreign object that
may be impeding breathing if the client is choking and unable to speak or cough strongly.
D. Observe the client closely
-The nurse should observe the client closely at this point in time. As long as the client is able to
cough strongly, the nurse does not need to intervene.

 

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