Nursing Scenarios: Client Care and Decision Making, Exams of Nursing

Download Nursing Scenarios: Client Care and Decision Making and more Exams Nursing in PDF only on Docsity! ATI RN COMPREHENSIVE PREDICTOR 2024/25 LATEST BEST GUIDE TO GRADE A+ ATI COMPREHENSIVE PREDICTOR VERSION 1 COMPLETE (180) QUESTIONS AND ANSWERS LATEST 2024/2025> 1. The nurse cares for a client diagnosed with superficial partial thickness burn. Thenurse should assign the client to a room with which client? A. A client diagnosed with Cushing’s Syndrome. B. A client Diagnosed with cellulitis of the left leg. C. A Client diagnosed with acute peritonsillar abscess. 5. The nurse cares for a 6-month-old infant. The parents report that the infant hadsevere diarrhea for twelve hours. The nurse anticipates which finding? a. Normal skin elasticity. b. Depresses anterior fontanel. c. Pale yellow urine. d. Absent bowel sounds.Answer: B 6. The nurse cares for a client receiving hydrocodone every 6 hours prn for pain. The client reports pain at 1600. The nurse notes that the hydrocodone was last administered at1200, and the nurse proceeds to administer hydromorphone at 1615. After discovering theerror, how should the nurse record the occurrence? a. “Wrong pain tablet given early. Client will be monitored closely. Asleep now.” b. “Hydromorphone given instead of hydrocodone. Nursing supervisor aware of error.” c. Hydrocodone tablet ordered every 6 hours; pain medication given after 4 hours.Health care provider notified.” d. “Hydromorphone given at 1615; health care provider notified. B/P 122/80, RR 16.”Answer: D 7. The male client asks the nurse, “Why am I experiencing erectile dysfunction (ED)?”The nurse reviews the client’s medications. The nurse recognizes that which classification increases the risk for ED? a. Non-steroidal anti-inflammatory drugs. b. Antihypertensive medications. c. Anticoagulant medications. d. Histamine H2 inhibitors.Answer: B 8. The nurse in the hospital cafeteria overhears two nursing assistive personnel (NAP)discuss the client’s condition. What is the PRIORITY action for the nurse to take? a. Change the topic of the conversation. b. Report the employees to their nurse manager. c. Inform the employees about patient confidentiality and the client’s right to privacy. d. Meet with the employees at the end of the shift and tell them not to discuss clientsin a public place. Answer: C 9. The nurse cares for a client diagnosed with dehydration. The plan of care indicates the client is to drink two ounces of fluid every hour. The nurse determines the goal is met ifwhich is recorded on the intake and output (I&O) sheet for an eight-hour shift? a. 360 ml b. 160 ml c. 480 ml d. 240 ml 1 oz=30 ml; 60 oz*8= 480 mlAnswer: C 10. The nurse and LPN/LVN care for clients on a medical-surgical unit. The RN shoulddelegate which activity to the LPN/LVN? a. Follow up on the client’s report of chest and back itching two hours after starting apatient controlled analgesia pump. b. Provide instruction for the client receiving the first nicotine patch. c. Inform the health care provider of the client’s history of peptic ulcer disease priorto administration of streptokinase. d. Take the blood pressure and heart rate before administration of enalapril. Answer:D 11. The nurses care for the client diagnosed with tuberculosis. Before discontinuingairborne precautions, the nurse must confirm which? a. The tuberculin skin test is negative b. No acid-fast bacteria are in the sputum. c. The client has received anti-tuberculin medication for three days. d. The client’s temperature has returned to normal.Answer: B 12. The nurse cares for the client at 28 weeks gestation diagnosed with a complete placenta previa. The nurse determines discharge teaching is effective if the client makeswhich statement to her husband? a. I can go back to work tomorrow on a part-time basis b. I’m sorry to tell you we can’t have sexual relations c. I will still be able to have a vaginal birth d. I have to come back in 48 hours for a vaginal examAnswer: B 13. The nurse prepares the client diagnosed with myxedema for discharge. Whichaction should the nurse teach related to body temperature? a. “Alternate acetaminophen with ibuprophen every four hours for fever” b. “Take your temperature and record the results three times a day.” c. “Put on multiple layers of clothes until you fell comfortably warm.” d. “Use a heating pad during the day and electric blanket at night.”Answer: C Polycythemia. Answer: C 17. The nurse provides care for the client diagnosed with pneumonia who has posturaldrainage twice a day. Which client response indicates to the nurse that treatment is effective? a. “My upset stomach is better.” b. “I am coughing up more sputum.” c. “My cough is better.” d. “I don’t feel feverish anymore.”Answer: B 18. The risk management department plans a program to reduce errors. Which is the most common cause of errors in medication administration? a. Failure to follow routine policy and procedures. b. Caring for too many clients. c. Responsible for administering numerous medications. d. Unfamiliar with monk of the new pharmaceuticals ordered.Answer: A 19. The nurse cares for the school-aged child newly diagnosed with type 1 diabetes.The nurse instructs the family that the child’s insulin needs will decrease during which situation? a. Active exercise b. Infection c. Emotional stress. d. Pubert y. Answer: A 20. The nurse cares for the client receiving lactulose. The nurse determines themedication is effective if which is observed? a. The client’s weight increases by 5 pounds. b. The client denies shortness of breath. c. The client’s urinary output is 2000 ml daily. d. The client is alert and oriented to person, place and time.Answer: D 21. The nurse cares for the three-year-old prior to a surgical procedure. Whichbehavior indicates that the child is coping with preoperative preparation? a. The child hops around the room pretending to be a bunny while the nurse attemptsto obtain a blood pressure reading. 25. The intensive care nurse cares for the client two hours after a myocardial infarctionis diagnosed. The nurse’s PRIORITY is to focus on which action? a. Relieve pain. b. Prevent embolism. c. Monitor the telemetry. d. Reduce apprehension.Answer: A 26. The home health nurse instructs the family how to “allergy- proof” their preschooler’s bedroom. The nurse determines teaching is successful if which of thefollowing is observed? a. There are mini-blinds on the windows without curtains. b. The feather pillows are enclosed in double pillowcases. c. The child’s doll collection is displayed high on a shelf.There are no pictures hung on the walls. Answer: D 27. The nurse cares for infants in the newborn nursery. Which observation requires thenurse to contact the physician? a. The Asian female, 12 hours old, has a large bluish area noted across the sacrum andleft hip. b. An African-American make, 2 hours old, has fine bi-basilar crackles. c. Uneven skin folds are noted on a the upper legs of a Mexican- American female born6 hours ago. d. The anterior fontanel of a Caucasian male born 28 hours ago is moderately firm andflat. Answer: C 28. The nurse cares for the client diagnosed with partial thickness burns to the entiretyof both arms. Using the Rule-of-Nines, the nurse estimates the injury is which percentage? a. 18% b. 29% c. 36% d. 9% Answer: A 4.5% front and 4.5 % back, whole arm 9% 29. The home care nurse visits the client diagnosed with late stage Parkinson’s disease.The client sits in a wheelchair. Which statement, if made by the caretaker, indicates to the home care nurse teaching is effective? a. “My Client should push the hips up from the wheelchair for about 10 seconds everyhour or so.” b. “My client should elevate the knees with a pillow when lying in bed.” c. “I will limit my client’s time in the wheelchair to 30 minutes each day.” d. “I will encourage my client to change position every six hours.”Answer: A 30. The home care nurse makes a visit to the client diagnosed with heart failure. Theclient reports having difficulty sleeping at times. The nurse should take which action FIRST? c. How long have you been vomiting? d. Do you take insulin for your diabetes?Answer: C 36. The nurse prepares a list of delegated tasks for the nursing assistive personnel(NAP). Which task would be APPROPRIATE? a. Feed the client diagnosed with dysphagia related to a stroke b. Assist the client one day postoperatively to ambulate following knee replacement. c. Turn and reposition the client diagnosed with quadriplegia. d. Obtain vital signs for the client whose last B/P was 188/104Answer: C 37. The nurse cares for the client diagnosed with anorexia nervosa. The nurse shouldinclude which in the client’s plan of care? a. Allow as much time as needed for each meal. b. Observe client during and one hour after each meal. c. Explain the importance of an adequate diet. d. Use a random pattern for weigh assessments.Answer: B 38. The nurse cares for the client diagnosed with obsessive-compulsive personalitydisorder (OCD). Which does the nurse expect the client to demonstrate? a. Doubts, fears, and indecisiveness b. Marked emotional maturity. c. An elaborate delusional system. d. Rapid, frequent mood swings.Answer: A 39. The nurse prepares to administer medications. Which medication cannot be givendirectly intravenously? a. 50%dextrose b. Potassium chloride (KCI) c. Furosemide (Lasix) d. Calcium gluconate.Answer: B 40. The nurse cares for a client diagnosed with pancreatic cancer. When talking tothe client about the diagnosis, the nurse anticipates the client will make which statement? a. How can I have cancer when I don’t hurt anywhere on my entire body? b. I’ve been feeling fine and didn’t go to the doctor until my skin was kind of yellow. c. I should have known something was wrong when I gained 10 pounds in six weeks. d. My last couple of bowel movements have look almost black in color.Answer: B 41. The parent of an adolescent diagnosed with hemophilia calls the nurse to discussthe adolescent’s desire to participate in sports. Which activity should the nurse recommend? a. Soccer b. Gymnastics c. Swimming d. Snowboarding 46. The home care nurse cares for the client diagnosed with benign prostatic hyperplasia. The client reports not voiding since the previous evening. Assessment revealsa distended bladder. Which action should the nurse take NEXT? a. Apply gentle pressure over the client’s pubic area. b. Encourage the client to increase oral intake of fluids. c. Obtain an order for a straight catheter. d. Assist the client into a warm shower.Answer: C 47. The nurse assigns the nursing assistive personnel (NAP) to the mother who is firstday postpartum following a vaginal birth. Which tasks are appropriate for the nurse to delegate to the NAP? a. Check the location of the fundus twice a shift. b. Help the mother to ambulate shortly after delivery. c. Assist the mother with changing the perineal pad. d. Inform the mother about appropriate cord cake. e. Assist the mother with breast-feeding. f. Instruct the mother about cleansing the perineum.Answer: B,C 48. Two days after a short leg cast was applied for a fractured tibia, the client reportsnew, severe pain over the calf area. Which action should the nurse take FIRST? a. Instruct the client to elevate the leg above the heart. b. Obtain a cast cutter and elastic compression bandages c. Contact the health care provider. d. Assess bilateral deep tendon reflexes.Answer: C 49. The nurse counsels the client diagnosed with herpes simplex virus (HSV) infection. Which suggestion by the nurse BEST meet the client’s needs to cope with this diagnosis? a.Pamphlets about the disease and treatment. b. Web sites containing sexual transmitted disease (STD) information. c. Contact information for a local support group. d. Information about promising drug research.Answer: C 50. The nurse prepares the 3 year old for discharge after a tonsillectomy. The nurserecommends the parents offer the child which food during the first 24 hours? a. Cherry popsicle b. Vanilla milkshake c. Lemon-lime soft drink d. Cream of tomato soup.Answer: C 51. The client receives enteral nutrition at 50 ml/hour due to dysphagia. Which nursingaction diagnosis would be the priority? a. Risk for fluid volume excess. b. Risk for electrolyte imbalance. c. Risk for imbalanced nutrition. Less than body requirements. d. Risk for aspiration. a. Waist circumference is 75 cm b. Wait to hip ratio is 0.7 c. Body mass index is 31 kg/m2 d. Weight is 124 lbs.Answer: C More than 30, more than 25 overweight. Less than 19 underweight. 56. The nurse cares for the client reporting a burning sensation and itching of theright eye. On examination, the eye is red, with watery yellow discharge. The nurse understands which is the MOST likely cause of the client’s symptoms? a. Conjunctivitis b. Foreign body in the eye c. Allergic reaction d. Corneal abrasionAnswer: A 57. The nurse cares for the infant diagnosed with hydrocephalus immediately after placement of a ventriculoperitoneal (VP) shunt. The nurse should place the infant in whichposition? a. High Fowler’s Position b. Supine lying on the non-operative side c. Supine lying on the operative side d. Elevated 30 degreesAnswer: B 58. The nurse cares for the teenager recovering from mononucleosis. The teenager is upset and reports feeling too weak to resume normal home and social activates. The friends no longer come visit, and the parent is tired of “doing everything.” Which responseby the nurse is MOST appropriate? a. Medications exist that can boost strength and endurance after mononucleosis. b. Further diagnostic testing may be necessary to determine the cause of the fatigue. c. Convalescence is lengthy and people often report fatigue for several months. d. You need to make more of an effort to participate in normal activities. Answer: C 59. The nurse cares for a client after an involuntary admission to a mental health facility due to threatening to harm self. The family asks the nurse if they can take the clienthome. Which response by the nurse is MOST appropriate? a. I will speak to the health care provider about your request. b. The client is lucky to have a loving family like you. c. The courts determine how long the client is hospitalized. d. Why do you want to take the client home?Answer: C 60. The nurse cares for the adolescent diagnosed with Hodgkin’s lymphoma. The adolescent receives nitrogen mustard, vincristine, 66. When providing respiratory care for the client with a tracheostomy, it is MOSTimportant for the nurse to take which action? a. Keep the trach cuff inflated during suctioning. b. Apply suction as the catheter is being inserted. c. Instill acetylcysteine just prior to suctioning. d. Preoxygenate the client prior to suctioning. Answer: D 67. The nurse provides care to a client diagnosed with cirrhosis. Which is the BESTexplanation for the development of edema? a. Decreased concentration of plasma albumin. b. Decreased production of aldosterone causing sodium and water retention. c. Shunting of the blood from the portal vessels into the lower pressure vessels. d. Inadequate formation, use and storage of vitamin K.Answer: A With cirrhosis there is malnutrition, with malnutrition there is decreased albumin, withdecreased albumin there is edema. 68. Nurses working in hospital environments should follow which guideline related toeffective hand washing? a. Use a petroleum-based lotion for prevention of dryness. b. Have the water temperature as hot as tolerated. c. Clean under artificial nails prior to starting shift. d. Wash for at least fifteen seconds covering all surfaces.Answer: D 69. The nurse cares for the primigravida during the transition phase of labor. Whichis MOST important for the nurse to include in the client’s plan of care? a. Provide feedback to reduce client’s anxiety. b. Assess client’s emotional reaction to impending parenthood. c. Catheterize client is unable to void for 2 hours. d. Provide comfort measures including position changes.Answer: D 70. The nurse cares for the client diagnosed with a hearing impairment. Which isa PRIORITY action for the nurse to take? a. Talk with a raised voice. b. Utilize more hand gestures. c. Speak at a slightly slower pace. d. Use more facial expressions.Answer: C 71. The nurse cares for the newborn with a port wine stain covering the face and half the body. The nurse notes that the mother refuses to look at the newborn. Which responseby the nurse is MOST appropriate? a. Allow the mother to recover from the fatigue of delivery and then bring thenewborn to her. b. Empathetically the mother not to blame herself for the newborn’s appearance. c. Talk to the family about the situation and encourage the family to comfort the other. miss you?Answer: B 76. The nurse cared for clients diagnosed with AIDS. The nurse recognizes which statementis true regarding therapy? 1. Pneumonia and influenza vaccines are contraindicated. 2. Protease inhibitors affect cell replication and have been successful. 3. Clients respond best when using single antiviral-type of medication. 4. Most of the medications used are administered by the IV route.Answer #2 Termination *vir 77. The nurse instructs the client about a lumbar puncture. In which position will the clientbe placed? 1. Lateral recumbent position. 2. Tredelenburg position. 3. Prone with the head turned to the left side. 4. High Fowler’s position.Answer#1 78. The nurse assists the client to obtain a sputum specimen. Which action should the nursetake first? 1. The nurse labels the container and places the specimen in a biohazards bag. 2. The nurse assists the client to perform mouth care. 3. The nurse instructs the client to expectorate into a sterile container. 4. The nurse performs hand hygiene and dons clean gloves.Answer#4 79. The nurse cares for a three-year-old child diagnosed with severe anemia. The nurseobserves weakness and fatigue. Which will the nurse expect to observe? 1. Cool, clammy skin. 2. Elevated blood pressure. 3. Cyanosis of the nailbeds. 4. Increased heart rate.Answer#4 80. The nurse cares for a child following corrective surgery for tetralogy of Fallot. Thenurse should include which in the child’s plan of care? 1. Place the child in a private room near the nursing station. 2. Restrict visitors with exception of the child’s parents. 3. Limit the child’s physical activity to sitting in a chair at bedside. 4. Instruct the child’s parent about food allowed on a 2 gram sodium diet. Answer#4 (low in sodium high in potassium because they will be on cardiac meds) 81. The nurse cares for a client diagnosed with pneumonia. The client receives intravenousantibiotic therapy twice daily. The client reports three liquid stools the past six hours. Which action should the nurse take FIRST? 1. Obtain an order for loperamide. Answer#4 86. The nurse determines which lunch menu is the BEST choice for a patient diagnosedwith fluid volume excess? 1. Turkey on wheat bread, carrot sticks, chocolate cake, 6 oz iced tea. 2. Sit-fry rice with soy sauce, green beans, ice cream, 6 oz water. 3. Pimento cheese with crackers, grapes, cookies, 4 oz diet soda. 4. Grilled cheese sandwich, dill pickle, apple, 4 oz tomato juice.Answer#1 LOW SODIUM DIET, WATER FOLLOWS SALT 87. The nurse teaches the mother of a 3-month-old infant. When planning accidentprevention, the nurse emphasizes which goal? 1. Electric outlets will be covered with plugs. 2. All small objects will be removed from the floor. 3. Crib rails will be kept in the highest position. 4. Toxic substances will be moved from lower storage.Answer#3 88. The nurse obtains a health history for the school-age child diagnosed with asthma. It ismost important for the nurse to follow up on which statement made by the child? 1. “I use a vaporizer in my room every night”. 2. “I play football and basketball”. 3. “I live in a rural area”. 4. “I snack on fresh fruit and raw vegetables”.Answer#3 89. The nurse cares for the client just admitted to the surgical unit from recovery after atotal hip replacement. It is MOST important for the nurse to take which action? 1. Elevate the affected extremity on pillows. 2. Position the client in high Fowler’s position. 3. Place the client in Buck’s traction. 4. Position the client with the legs abducted.Answer#4 ABDUCTION SPLINTER OR TWO PILLOWS BETWEEN LEGS 90. The nurse cares for the school-age child receiving phenytoin. The nurse should observefor which known adverse effect? 1. Hyperactivity several hours after ingestion. 2. Gingival hyperplasia. 3. Flushed face within an hour of ingestion. 4. Pinpoint pupils. Answer#2 (phenytoin =Dilantin=anticonvulstant) 91. The nurse cares for the child diagnosed with cystic fibrosis. The nurse should interveneif the child is eating which food? 1. Chili. 2. Roasted chicken tenders. 3. A vanilla milkshake. 4. Slice of watermelon.Answer#3 LOW FAT, HIGH PROTEIN, HIGH CARB AND CALORIES 92. The client diagnosed with type 1 diabetes reports to the nurse, “I feel really nervous andjittery all over”. The nurse notes regular insulin was administered two hours ago. Which action should the nurse take FIRST? 1. Review all medications the client has received. 2. Determine the client’s recent dietary intake. 3. Administer a simple carbohydrate. 4. Request laboratory draw serum blood glucose.Answer#2 93. #1 94. #2 95. The nurse cares for the client diagnosed with bipolar disorder. The nurse determineswhich activity is appropriate for the client during a period of mania? Select all that apply. 1. Relaxation exercises. 2. Playing board games with other clients. 3. Watching the television. 4. Scheduled rest periods. 5. Aerobic exercises. 6. Listening to soft music.Answers#1,4,5,6 96. The health department nurse cares for the client diagnosed with tuberculosis andpositive HIV status, sharing concerns over financial and childcare issues and life expectancy. Which referral is MOST appropriate for this client? 1. A non-denominational chaplain. 2. Financial counselor at a non-profit agency. 3. Social worker from social services department. 4. Topical nonopioid analgesic.Answer#1 102. The nurse on the pediatric unit receives report from the previous shift. Which clientshould be seen FIRST? 1. The 8 year old newly diagnosed with type 1 diabetes with a blood sugar of 285mg/dl. 2. The 2 year old diagnosed with asthma whose pulse oximeter reading is 97%. 3. The 6 year old recovering from an appendectomy with a temperature of 100.3degrees F (37.9 degrees C). 4. The 10 year old with cerebral palsy with a newly placed enteral nutritionAnswer#1 RISK FOR DKA 103. The nurse instructs the client receiving enoxaparin (LOVENOX). Which client responseindicates teaching is EFFECTIVE? 1. I will inject the medication into the far left or right side of my abdomen every day. 2. I can take ibuprofen if I am feeling pain. 3. The antidote to enoxaparin is Vitamin K. 4. I am taking enoxaparin to dissolve blood cloths.Answer#1 (ANTIDOTE: Protamine sulfate) 104. The nurse cares for the client receiving acyclovir. The nurse knows acyclovir is used totreat which condition? 1. Herpes simplex. 2. Contact dermatitis. 3. Candidiasis. 4. Psoriasi s.Answer#1 105. The nurse admits the 6-month old infant diagnosed with hypovolemia secondary to diarrhea. The physician orders KCL 1 mEq per kg/body weight in 250 ml 0.9% saline. Priorto administering the medication, which action should the nurse take FIRST? 1. Validate the baby has wet a diaper. 2. Determine the possible causes for the diarrhea. 3. Offer the electrolyte solution orally. 4. Arrange for a central line catheter placement.Answer#1 No PEE no K!!!!!! 106. The nurse cares for the client diagnosed with spinal cord injury at the level of T1. Thenurse notes the client is flushed and sweating profusely. The client reports a headache andnausea. The vital signs are blood pressure 140/98 and heart rate 38 beats per minute. Which action should the nurse take FIRST? 1. Administer antihypertensive medication. 2. Palpate the client’s bladder. 3. Position the client in a supine position. 4. Place the client on a cardiac monitor.Answer#2 ASSESS FIRST ;IPPA (she inspected and now palpate) 112. The nurse cares for the client following a vegan diet. The nurse recognizes which mealselection is BEST? 1. Scrambled eggs, wheat toast, coffee, and cantaloupe. 2. Bagel with peanut butter, strawberries and orange juice. 3. Bran flakes, soy milk, grapefruit and tofu. 4. Fresh fruit, yogurt, blueberry muffin, and tea.Answer#3 ONLY EATS VEGETABLE PRODUCTS. 113. The nurse assists the client to breastfeeding the baby for the first time. Whichobservation by the nurse indicates that the baby is nursing appropriately? 1. Swallowing noises can be heard. 2. The baby’s head is turned toward the mother’s breast. 3. The client reports a pinching sensation as the baby sucks. 4. The baby’s cheeks are dimpled with each suck.Answer#1 114. At 1500, the nurse begins the infusion of packed red blood cells (PRBC’s). The clientasks the nurse when the transfusion will be completed. Which response by the nurse is accurate? 1. The transfusion will be completed by 2000. 2. The transfusion will be completed by 1600 3. The transfusion will be completed by 1800. 4. The transfusion will be completed by 2200.Answer#3 (infuse 3-4 hrs) 115. The community nurse instructs the client receiving isoniazid. The nurse is MOSTconcerned if the client makes which statement? 1. I will not eat tuna sandwiches. 2. I will frequently wash my hands. 3. I will limit my alcohol intake to 1 beer/day. 4. I will eat small, frequent feedings. Answer#3 (alcohol increases risk for hepatotoxicity, wrong statement shouldn’t drink) 116. The nurse prepares to administer an intramuscular injection to the one-year-old infant. The infant is in the 70th percentile for height and weight. The nurse determineswhich injection site is MOST appropriate? 1. Vastus lateralis. 2. Deltoid. 3. Ventrogluteal. 4. Abdome n. Answer#1 117. The nurse plans a burn prevention program for older adults. What is the bestdescription of the cause of burns in the elderly population? 1. Frayed electrical wires. 2. Pots and pans on a stove. 3. A lighted cigarette. 4. A bathtub of hot water.Answer#2 118. Prior to administration of a cleansing enema, the nurse explains the procedure to theclient. Which statement, if made by the client to the nurse, indicates further teaching is necessary? 1. I have to lie on my right side while you put the solution in me. 2. You’ll put in about the same amount of fluid that’s in a full IV bag. 3. You want to see the returns in the toilet before I flush. 4. If I feel I can’t hold any more of the fluid, I’ll tell you to stop for a moment. Answer#1 (position on Left Sim’s position to allow the solution to flow by gravity) 119. The nurse cares for the adolescent diagnosed with asthma. Which is the MOSTappropriate response by the nurse? 1. The cause of the wheezing is the collapse of the small air sacs in your lungs. 2. There is a narrowing of airways going to your lungs. 3. The wheezing is due to fluid in the space surrounding your lungs. 4. The wheezing is due to inflammation in your nose and throat.Answer#2 120. The nurse cares for the unconscious client after a motor vehicle accident. The nursedoes a quick physical assessment and remarks, “He must have a history of chronic emphysema”. The basis for the nurse’s judgment was the presence of which finding? 1. A rounded chest and clubbing of nails. 2. Cyanosis around the patient’s mouth. 3. An ipratropium inhaler in the shirt pocket. 3. Assess the distal pulses every 15-30 minutes. 4. Provide the client with fluids to drink. 5. Reinforce the pressure dressing. 6. Immediately call for an electrocardiogram (ECG) if the client has chest pain.Answers#1,2,4 126. The nursing instructor reviews electrolytes and discusses common causes for hypercalcemia. The instructor determines teaching is effective when the student choosewhich as a common cause of hypercalcemia? 1. Malnutrition. 2. Bone malignancy. 3. Hyperthyroidism. 4. Long-term use of furosemide. Answer#2 (the bone releases calcium into the bloodstream) 127. The nurse cares for the client two days after surgery. As the nurse hangs a new bag of IV fluids, the client reports sudden chest pain and says. “I can’t breathe”. What would be thenurse’s FIRST action? 1. Insert an intravenous line and obtain an apical heart rate. 2. Place the client in high Fowler’s position and auscultate the lungs. 3. Determine if the client has a history of cardiac problems. 4. Ask the nursing assistant personnel to stay with the client while the nurse callsRespiratory Therapy. Answer#2 128. The nurse receives a call from a client. The client reports having dark- colored bowelmovement. Which action by the nurse is MOST appropriate? 1. Determine if the client is taking ferrous sulfate. 2. Instruct the client to see the health care provider as soon as possible. 3. Tell the client to continue monitoring the bowel movement. 4. Ask if the client as eaten new foods.Answer#1 129. The nurse cares for the client diagnosed with type 2 diabetes and an infection in theleft foot. Which observation MOST concerns the nurse? 1. The wound site shows evidence of granulation.2. WBC 8,300/mm3. 3. Erythrocyte sedimentation rate (ESR) 28.2 mm/h4. T 99.2 F (37.3 C), P 88, R 18, BP 120/76 Answer#3 NORMAL < 25 : rate at which erythrocytes settle out of anicoagulated blood in 1 hour,detects illness associated with inflammation, necrosis. 130. The nurse cares for the client diagnosed with advanced Parkinson’s disease. Whichactivity is MOST appropriate to decrease fatigue? 1. Establish a regular bed time. 2. Provide for morning and afternoon naps. 3. Avoid high carbohydrate foods. 1. I need to make every effort to avoid sneezing, coughing, or vomiting. 2. I have to sleep with this eye shield on but can wear my glasses during the day. 3. I should call the doctor if I start seeing double or flashes of light. 4. It’s okay to bend over and pick up my grandchild if I am wearing my eye shield.Answer#4 136. The nurse cares for the client in active labor. The client reports contractions started about 3 hours ago. The contractions occur every 4-5 minutes lasting for about 1 minute. The client’s water broke about an hour ago, and the pains are getting worse. Which action should the nurse take first? 1. Administer oxygen 2 L/min by nasal cannula. 2. Place external uterine and fetal monitors on the client’s abdomen. 3. Assist the client into a high-Fowler’s position. 4. Instruct the partner to model pursed-lipped breathing.Answer#2 137. The client is scheduled for a pelvic ultrasound. Prior to the procedure it is MOSTimportant for the nurse to take which action? 1. Encourage the client to completely empty her bladder. 2. Administer a mild sedative. 3. Instruct the client to drink several glasses of water. 4. Obtain an informed consent.Answer#3 138. The nurse cares for a client diagnosed with amnesia after a motor vehicle accident. The client’s friend was killed in the accident, and the client was arrested for driving whileintoxicated and speeding. Which is the MOST likely cause of the amnesia? 1. Repression. 2. Suppression. 3. Projection. 4. Dissociatio n. Answer#4 139. The nurse teaches the parent of an infant after repair of cleft lip and palate. Which isthe BEST solution to remove dried food and drainage from the suture line? 1. Hydrogen peroxide. 2. A mild antiseptic solution. 3. Normal saline. 4. Providone-iodine solution.Answer#3 140. The nurse on a medical-surgical unit received report. Which clients should the nursesee FIRST? 1. The client diagnosed with heart failure and dementia trying to get out of bed. 2. The client two days after a total hip replacement with a hemoglobin of 12.9 gm/dl. 3. The client receiving one unit of packed red blood cells with an IV pump sounding analarm. 4. The client 12 hours after a laparoscopic cholecystectomy states, “My shoulderhurts”. Answer#1 141. The nurse instructs an adolescent diagnosed with a sprained left ankle. Furtherteaching is required if the adolescent makes which statement? 1. I will elevate my ankle when I am sitting. 2. I will try to keep weight off the ankle for several days. 3. I will put a heating pad on my ankle as soon as I get home. 4. I will keep my ankle wrapped with an elastic compression bandage.Answer#3 RICE: rest, ice, compression, elevation 142. The client in the psychiatric unit tells the nurse, “I know you are trying to poison me,I’m not taking those pills”, which statement, if made by the nurse is MOST appropriate? 1. It’s alright if you don’t want to take the pills right now. You can take them later. 2. I’m not trying to poison you, why do you say that? 3. It sounds like you are afraid that the staff might hurt you, this is a medication to helpyou. 4. These pills came straight from the pharmacy just like everyone else’s. Why do youthink they are poisonous? Answer#3 143. The nurse teaches the client diagnosed with Addison’s disease. What is MOSTimportant to include in the instructions? 1. Limit physical exertion. 2. Frequent consultations with the health care provider. 3. Adhere to a low sodium diet. 4. Take hormone replacement therapy as prescribed.Answer#4 144. The nurse identifies which client is at GREATEST risk for developing 3. Perform an intermittent bladder catheterization. 4. Speak to the health care provider about the results of a client’s complete bloodcount. 5. Ambulate the mother after cesarean birth to the bathroom. 6. Obtain the vital signs on the client ready for discharge.# 1,2,5,6 149. The nurse cares for the child diagnosed with a closed head injury. It is most importantfor the nurse to assess which finding? 1. The child’s response to the environment. 2. The child’s intake and output. 3. The child’s vital signs. 4. The child’s motor activity. Answer#1 (level of consciousness) 150. The staff nurse asks for the goals of the Quality Assurance Committee. Which is anexample of a goal? 1. Use of an alternate laundry service. 2. Explore an increase of handicap parking spaces. 3. Survey documentation of follow-up after administration of pain medication. 4. Determine the cause for employee’s tardiness.Answer#3