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ATI COMPRHENSIVE A CAPSTONE QUIZ
WITH ACTUAL CORRECT ANSWERS
...
A client who has a diagnosis of complete placenta previa is admitted to
the labor and delivery suite at 36 weeks gestation with contractions 5 min
in frequency and 1 min in duration
...
Rupture the amniotic sac
B
...
Prepare the client for a cesarean section
D
...
A nurse is caring for a toddler who has respiratory syncytial virus
...
Wear an N95 respiratory mask while caring for the toddler
B
...
Use a designated stethoscope when caring for the toddler
D
...
A nurse is performing a skin assessment for a client who is on bedrest
...
Encourage client fluid intake of 2,500 mL daily
B
...
Place a dehumidifier in the client's room

D
...
A nurse from the State Health Development is instructing a group of
nurses regarding reportable infections
...
Herpes simplex virus 2
B
...
Staphylococcus aureus
D
...
A nurse is planning care for a client following gastric bypass surgery
...
Limit your meals to three times per day
B
...
Start each meal with a protein source
D
...
A community health nurse is teaching a group of restaurant workers
about hepatitis A
...
Manifestations first appear 6 months after exposure to the virus
B
...
You can get hepatitis A by eating undercooked pork products

D
...
A home health nurse is admitting a client who is prescribed peritoneal
dialysis
...
Confirm schedule for delivery of supplies
B
...
Demonstrate how to perform the procedure
D
...
A nurse is performing an admission assessment for a client who is to
undergo a colonoscopy
...
Which of the following
medications is the priority to report to the provider?
A
...
Clopidogrel
C
...
Digoxin - CorreCt Answers -Metformin

8
...
The
nurse should assess for which of the following potential contraindications?
A
...
History of smoking
C
...
Family history of malignant hyperthermia - CorreCt Answers -Shellfish
allergy

9
...
Which of the following statements should the
nurse make?
A
...
Avoid discussing the funeral when your child is around
C
...
School-age children tend to view death as a temporary form of sleep CorreCt Answers -School-age children tend to view death as a temporary
form of sleep

10
...
Which of the
following is the highest priority for the client to report to the provider?
A
...
Dry mouth
C
...
Constipation - CorreCt Answers -Fever
11
...
Which of the following statements should the nurse
document in an incident report?
A
...
Client's roommate thinks the client is confused and fell when getting out
of bed
C
...
Client found lying on the floor near the bedside table - CorreCt Answers Client found lying on the floor near the bedside table

12
...
Which of the following clients is appropriate
to assign to the float nurse?
A
...
A 4-year-old client who has a Wilms tumor and is receiving
chemotherapy
C
...
A 14-year-old client who is scheduled for discharge today following
placement of a Herrington rod - CorreCt Answers -A 10-year-old client who
has pneumonia and is receiving respiratory treatments

13
...
The nurse should plan to monitor for which of the
following adverse reactions?
A
...
Ototoxicity
C
...
Hypertension - CorreCt Answers -Ototoxicity

14
...
Which of the
following findings should the nurse expect?
A
...
Elevated urine specific gravity
C
...
Increased hematocrit - CorreCt Answers -Thready pulse

15
...
The client has two school-age children and a
limited support system
...
Inform the client of available community resources
B
...
Agree upon short-term goals for the client
D
...
A nurse in an emergency department is assessing a client who has a
nasal fracture
...
Clear fluid drainage from the nares
B
...
Dried blood in the mouth
D
...
A nurse in an urgent care clinic is collecting admission history from a
client who is at 16 weeks of gestation and has bacterial vaginosis
...
Profuse milky white discharge
B
...
Low-grade fever

D
...
A nurse is discussing the z-track administration of hydroxyzine with a
newly licensed nurse
...
This technique prevents injury to the sciatic nerve
B
...
This technique allows a larger amount of medication to be injected
D
...
A nurse is caring for a full-term newborn immediately following birth
...
Instill erythromycin ophthalmic ointment in the newborn's eyes
B
...
Place identification bracelets on the newborn
D
...
A nurse is planning to provide community education about viral
hepatitis
...
A series of four hepatitis vaccines is recommended to prevent viral
hepatitis
B
...
Chronic hepatitis can lead to renal cell cancer

D
...
A nurse in a residential mental health facility is planning care for a new
client who has obsessive compulsive disorder
...
Work with the client to create a flexible daily schedule
B
...
Offer solutions to assist in problem solving
D
...
A nurse is assessing an adult male who has a BMI of 20
...
Healthy weight
B
...
Overweight
D
...
A nurse is caring for a client who is nulliparous and in the first stage of
labor
...
At the end of the last contraction, the nurse observes a
large gush of fluid coming out of the client's perineal area
...
Perform another internal exam
B
...
Check the FHR
D
...
A nurse is creating a plan of care for a client who has anorexia nervosa
...
Encourage the client to gain 2
...
Weigh the client once per week throughout hospitalization
C
...
Allow the client to choose meal times - CorreCt Answers -I think its D

24
...
The nurse should understand that a
suspicious lesion is
A
...
Scaly and red
C
...
Firm and rubbery - CorreCt Answers -Asymmetric, with variegated
coloring

25
...
Which of the following actions should the nurse take?
A
...
Stand on the right side of the client when examining the left eye
C
...
Place the ophthalmoscope directly against the client's forehead - CorreCt
Answers -Dim the lights in the room prior to the examination

26
...

Which of the following actions should the nurse identify as an indication
that the newly licensed nurse understands wound irrigation?
A
...
Administers PO analgesia 20 min prior to irrigation
C
...
Irrigates the wound from the top to the bottom - CorreCt Answers Administers PO analgesia 20 minutes prior to irrigation

27
...
Which of the following
interventions should the nurse include in the plan of care?
A
...
Maintain the head at a midline position
C
...
Perform neurological checks every 4 hrs - CorreCt Answers -Maintain
the head at a midline position

28
...
After moving the client to safety, which of the followings
is the priority action?
A
...
Close the fire doors on the unit
C
...
Put out the fire with the appropriate extinguisher - CorreCt Answers Close the fire door on the unit

29
...
Which of the following
statements should the nurse make?
A
...
Your parent will have to take the medication that the doctor prescribes
C
...
The provider can prescribe restraints if your parent tries to harm others CorreCt Answers -The provider can prescribe restraints if your parent tries
to harm others

30
...

Which of the following findings should the nurse expect?
A
...
Agnosia
C
...
Aphasia - CorreCt Answers -Hallucinations

31
...
The nurse should identify that which of the following
findings indicates fluid overload?
A
...
Bradycardia
C
...
Bounding pulses - CorreCt Answers -Bounding pulses

32
...
Which of the
following findings places the client at risk for delayed wound healing?
A
...
1
B
...
HbA1c 5
...
Uncontrolled pain - CorreCt Answers -Hyperemesis

33
...
Which of the following findings indicates
to the nurse that the treatment is effective?
A
...
Pedal pulses 2+
C
...
Distended jugular veins - CorreCt Answers -Heart rate greater than
60/min

34
...
Which of the
following findings should indicate to the nurse that the medication is
effective?
A
...
Weight loss
C
...
Absence of seizures - CorreCt Answers -Weight loss

35
...
Which of the following clients should the nurse instruct to come to
the clinic?
A
...
A client who had an intrauterine device inserted yesterday and has
cramping and bleeding
C
...
A client who has sharp pain in her shoulder following a laparoscopic
tubal ligation yesterday - CorreCt Answers -A client who has sharp pain in
her shoulder following a laparoscopic tubal ligation yesterday

36
...
The nurse should evaluate which of the following
laboratory tests to determine effective long-term management of blood
glucose levels?
A
...
HbA1c
C
...
Urinalysis for ketones - CorreCt Answers -HbA1C

37
...
Which of
the following precautions should the nurse take while caring for this client?
A
...
Insert an indwelling urinary catheter to monitor urinary output
C
...
Use a dedicated stethoscope - CorreCt Answers -Use a dedicated
stethoscope

38
...

Which of the following instructions should the nurse provide to the client?
A
...
Plan to take clozapine for the next 6 months
C
...
Learn to use projection to adapt to stressful experiences - CorreCt
Answers -Participate in a 12-step program

39 A nurse is caring for a client who reports difficulty falling asleep at night
...
Encourage the client to ambulate in the hallway 1 hr before bedtime
B
...
Schedule routine care tasks during hours when the client is awake
D
...
A nurse is planning care for a newborn who has hyperbilirubinemia and
is to receive phototherapy
...
Clothe the newborn in light cotton
B
...

C
...
Place the newborn 45 cm from the light source - CorreCt Answers -Place
the newborn 45 cm from the light source

41
...
Which of the following
instructions should the nurse include?
A
...
Lay down for 30 min after meals
C
...
Eat a dry carbohydrate before getting out of bed - CorreCt Answers -Eat
a dry carbohydrate before getting out of bed

42
...
Which of the following
information should the nurse include in the teaching?
A
...
You should use a 5-milliliter barrel syringe to flush your PICC line at
home
C
...
You should immobilize the arm with the PICC line using a sling CorreCt Answers -Your PICC line will allow long-term access for antibiotic
therapy

43
...
Which of the following referrals
should the nurse make?
A
...
Speech-language pathologist

C
...
Recreational therapist - CorreCt Answers -Social worker

44
...

The nurse sits down to talk with an adolescent client who was admitted
with clinical depression
...
You looked like you would be the most likely to talk back with me
B
...
Why shouldn't I talk to you? You looked lonely
D
...
An occupational health nurse at a group of health care clinics is
planning activities to prevent and control the spread of communicable
disease
...
Influenze immunizations
B
...
Presentations about safer sex practices
D
...
A nurse is caring for a client who has heart failure and has started
taking a loop diuretic
...
Decreased reflexes

B
...
4 kg
C
...
Jugular vein distention - CorreCt Answers -Decreased reflexes

47
...
Which
of the following assessment findings should indicate to the nurse that the
NG tube might not be functioning properly?
A
...
Drainage fluid is greenish-yellow
C
...
Abdominal rigidity - CorreCt Answers -Abdominal rigidity

48
...

Which of the following findings should the nurse expect?
A
...
Urinary output 30 mL/hr
C
...
Heart rate 152/min - CorreCt Answers -Heart rate 152/min

49
...
Why not end my misery?" Which of the following responses
by the nurse is appropriate?
A
...
You can trust me and tell me what you are thinking?
C
...
Do you have to plan to end your life? - CorreCt Answers -Do you have a
plan to end your life?

50
...
Which of the
following findings is the nurse's priority?
A
...
The client refuses to take prescribed oral risperidone
C
...
The client's thoughts jump rapidly from one idea to the next when
speaking - CorreCt Answers -The client reports hearing voices

51
...
Which of the following client
reports should the nurse assess first?
A
...
Indigestion
C
...
Urinary frequency - CorreCt Answers -Indigestion

52
...
Which of the following actions by the assistive personnel
requires the nurse to intervene?
A
...
Elevates the head of the client's bed
C
...
Checks the client's pulse oximetry - CorreCt Answers -Offers oral fluids
to the client

53
...
The nurse should identify that which of the following findings
is a contraindication for taking this supplement?
A
...
The client has a history of a seizure disorder
C
...
The client has a history of rheumatoid arthritis - CorreCt Answers -The
client takes aspirin daily

54
...
Which of the following actions should the nurse take when
conducting the interview?
A
...
Seat the client at least 3
...
Position the client's chair between the nurse's chair and the door
D
...
7m from the nurse

55
...

Which of the following clients should the nurse assess first?
A
...
A 48 year old client who has AIDS, pneumocystic pneumonia, and a
temperature of 38
...
A 60 year old client who has COPD, is receiving 2 L/min O2 via a nasal
cannula, and has an oxygen saturation of 89%
D
...
A nurse is assessing a client prior to performing a blood draw
...
Peanuts
B
...
Avocados
D
...
A nurse is planning discharge teaching for a client who is scheduled to
receive intravenous infusions at home
...
Plug the infusion pump in an outlet next to the bathroom
B
...
Clean the infusion pump when it is turned on
D
...
A nurse is preparing to witness a client's signature on an informed
consent for a total knee arthroplasty
...
I wonder if the metal in my knee will show up in airport screenings

B
...
I look forward to being able to bend my knee again when I sit in a chair
D
...
A nurse plans to ambulate a client on the third day after cardiac surgery
...
Provide the client with a water
B
...
Obtain the client's vital signs and oximetry prior to ambulation
D
...
A nurse is planning the discharge of an infant who has tetralogy of
Fallot
...
Portable suction
B
...
Hemodialyzer
D
...
A nurse is admitting a client who has antisocial personality disorder
...
Compulsive attention to details

B
...
Uses others for personal gain
D
...
A nurse is teaching the parent of a school-age child who has scabies
about the application of permethrin 5% cream
...
Burning
B
...
Photosensitivity
D
...
A nurse is teaching a client who has a new prescription for digoxin
...
"Notify your provider if you experience muscle weakness
...
"Reports a weight gain of one-half pound per day
...
"Expect this medication to increase your blood pressure
...
"You will need to take a diuretic while taking this medication
...
A nurse is planning teaching for a client who is at 10 weeks of gestation
and has a history of urinary tract infections
...
Decrease intake of citrus foods and beverages

B
...
Empty the bladder before and after intercourse
D
...
A nurse is providing discharge teaching to a client who is postpartum
and plans to breastfeed
...
Vitamin D
B
...
Vitamin A
D
...
A nurse is caring for a client who has been taking propranolol
...
Blood pressure 156/90 mm Hg
B
...
Potassium 5
...
Sodium 130 mEq/L - CorreCt Answers -Pulse 54/min

67
...
Which of the following
instructions should the nurse include?
A
...
"
B
...
"
C
...
"

D
...
" - CorreCt
Answers -Try to have your baby empty your breasts with each feeding

68
...

Which of the following findings requires immediate intervention by the
nurse?
A
...
Serum sodium 138 mEq/L
C
...
6C
D
...
A nurse is caring for a client who reports chest pain
...
aPTT 80 seconds
B
...
8 ng/mL
C
...
Human B-type natriuretic peptide 88 pg/mL - CorreCt Answers Troponin I 1
...
A nurse is assessing a client who has a fentanyl patch in place for
chronic pain
...
No bowel movement for 3 days
B
...
Respiratory rate 14/min

D
...
8 mEq/L - CorreCt Answers -No bowel movement for
3 days

71
...
Which of the following statements by the
client indicates an understanding of the teaching?
A
...
"
B
...
"
C
...
"
D
...
" CorreCt Answers -I will take this medication with 8 ounces of water

72
...
Which of the following findings should indicate to the nurse the
client is at risk for aspiration?
A
...
The client sits upright in bed during meals
C
...
The client has a cough reflex - CorreCt Answers -The client pockets food
on one side of his mouth

73
...
Which of the following clients
should the nurse assign to an assistive personnel?
A
...
A client who had a myocardial infarction 3 days ago and reports chest
pain

C
...
A client who has awoken following a bronchoscopy and requests a drink CorreCt Answers -A client who had a stroke 2 days ago and needs help
toileting

74
...
Which of the following actions should the
nurse take?
A
...
Replace the extension tubing every 48 hrs
C
...
Increase the infusion rate - CorreCt Answers -Discard opened cans of
formula after 24 hrs

75
...
Based on the client's chart findings, which of the following actions
should the nurse plan to take?
A
...
Withhold digoxin
C
...
Administer ferrous sulfate - CorreCt Answers -Withhold digoxin

76
...

Which of the following diagnostic assessments should the nurse
recommend for all new employees to screen for the presence of
tuberculosis?
A
...
Chest x-ray
C
...
Mantoux test - CorreCt Answers -Mantoux test

77
...
Which of the following statements by the parent indicates
an understanding of the teaching?
A
...
"
B
...
"
C
...
"
D
...
" CorreCt Answers -I should place my baby's car seat rear-facing until 6
months of age

78
...
Which of the following medications places the fetus at risk
for teratogenic effects?
A
...
Phenytoin for seizure disorder
C
...
Ferrous sulfate for chronic anemia - CorreCt Answers -Phenytoin for
seizure disorder

79
...
Which of the following children should the
nurse have the provider evaluate first?

A
...
A child who has a compound fracture of the femur and is crying in pain
C
...
A child who has several missing permanent teeth and a swollen,
ecchymotic upper lip - CorreCt Answers -C

80
...

For which of the following findings should the nurse monitor as a potential
complication of TPN?
A
...
Respiratory depression
C
...
Electrolyte imbalance - CorreCt Answers -Electrolyte imbalance

81
...
Which finding should the nurse anticipate in a client who has
fluid volume deficit?
A
...
Decreased hematocrit
C
...
Lower urine specific gravity - CorreCt Answers -Elevated blood urea
nitrogen

82
...

Which of the following findings indicates the treatment has been effective?

A
...
The child has increased nasal secretions
C
...
The child develops diminished breath sounds - CorreCt Answers -The
child has increased sputum production

83
...
Which of
the following actions should the nurse take first?
A
...
Identify the reason for the client's refusal
C
...
Inform the provider of the client's refusal - CorreCt Answers -Identify
the reason for the client's refusal

84
...
Which of the following should the nurse
include?
A
...
Recommending the client may return to work after two negative sputum
cultures
C
...
Teaching the client's family to wear protective masks while with the
client - CorreCt Answers -Educating the client how to cover the nose and
mouth with tissues when coughing

85
...

Which of the following actions should the nurse take?
A
...
Quarantine the client
C
...
Begin prophylactic treatment with ciprofloxacin - CorreCt Answers -D

86
...
Which of the following is an
appropriate action for the nurse to take?
A
...
Keep a 3 foot distance from the radiation implant
C
...
Require the client wear a dosimeter badge - CorreCt Answers -C

87
...
Which of the
following actions should the nurse take first?
A
...
Observe the client's level of mobility
C
...
Electronically enter the prescriptions from the provider - CorreCt
Answers -Observe the client's level of mobility

88
...
Which of the following
findings indicates decreased cardiac output?
A
...
Constricted pupils
C
...
Bradypnea - CorreCt Answers -Oliguria

89
...
The nurse should plan to notify the
provider of which of the following findings?
A
...
Positive Babinski reflex on bilateral feet
C
...
Pinna below the outer canthus of the eye - CorreCt Answers -Pinna
below the outer canthus of the eye

90
...
Which of the
following instructions should the nurse include in the teaching?
A
...
Dissolve the capsules in a glass of chocolate milk
C
...
Administer the medication at bedtime - CorreCt Answers -Administer
the medication with a glass of orange juice

91
...
Which of
the following should the nurse identify as a reportable diagnosis to the
CDC?
A
...
Hepatitis A

C
...
Pediculosis capitis - CorreCt Answers -Hepatitis A

92
...
Which of the following should the nurse
include?
A
...
Vomited a large amount of emesis immediately after surgery
C
...
9% sodium chloride
D
...
A charge nurse is evaluating the time management skills of a newly
licensed nurse
...
Delegates creation of a client's teaching plan to a licensed practical nurse
B
...
Focuses on activities rather than objectives
D
...
A nurse is caring for a client who has a prescription for atorvastatin
...
Hepatitis C
B
...
Peptic ulcer disease

D
...
A nurse delegates tasks to a licensed practical nurse and an assistive
personnel
...
Insert an indwelling catheter if the client has not voided in 3 hr
B
...
Assess and document the level of consciousness every hour
D
...
A nurse is assessing a client who has a long arm cast
...
Edema
B
...
Petechiae
D
...
A nurse is caring for a client who has opioid use disorder and is
experiencing withdrawal
...
Hyperreflexia
B
...
Euphoria
D
...
A nurse is caring for a client who is at high risk for developing diabetes
insipidus following a severe head injury
...
Urine specific gravity of 1
...
Urine output of 250 mL/hr
C
...
Blood glucose of 198 mg/dL - CorreCt Answers -Serum sodium of 115
mEq/L

99
...
When creating a sterile field, which of the following
actions should the nurse take?
A
...
6 cm below waist level
B
...
Place the sterile items within 1 cm of the edge of the sterile border
D
...
A nurse is caring for a client who is in labor and receiving electronic
fetal monitoring
...
Which of the following should the nurse expect?
A
...
Fetal hypoxia
C
...
Postmaturity - CorreCt Answers -Head compression

101
...
Which of the following medications should the nurse
expect the provider to prescribe?
A
...
Disulfiram
C
...
Clonidine - CorreCt Answers -Disulfiram

102
...
Which of the following response is the
priority for the nurse to make?
A
...
This discussion is only appropriate in a private area
C
...
Did you know you can be liable if you breach confidentiality? - CorreCt
Answers -Please stop this discussion

103
...
Which of the following actions should the nurse include in the
plan of care?
A
...
Adjust the length of the cane to equal the distance from the client's iliac
crest to the floor
C
...
Place the cane safely in the closet during naps and at bedtime - CorreCt
Answers -Remind the client to place the cane on the unaffected side

104
...
Which of the following should
the nurse include in the plan of care?
A
...
Remove dirty linens from the room after double bagging
C
...
Ensure family members remain at least 1 m from the client - CorreCt
Answers -Wear a dosimeter film badge while in the client's room

105
...
The client has visible contusions on all four
extremities
...
Report the incident to Adult Protective Services
B
...
Tell the client he must answer every assessment question
D
...
A home health nurse is assessing a client who reports a headache and
appears confused and drowsy
...
Which of the following actions should the nurse take first?
A
...
Wrap blankets around the client
C
...
Open the client's windows - CorreCt Answers -Take the client outdoors

107
...
The health benefit of this supplement combination is to do
which of the following?
A
...
Enhance the immune system
C
...
Improve joint functioning - CorreCt Answers -Improve joint functioning

108
...
The client states, "I feel like my incision ripped open
...
Which of the following actions should the
nurse take?
A
...
Place the client in a low-Fowler's position
C
...
Apply a dry gauze dressing to the incision - CorreCt Answers -Extend the
client's legs above heart level

109
...
When
speaking to the client, the nurse should incorporate which of the following
communication methods?
A
...
Rephrase sentences the client does not understand
C
...
Exaggerate lip movements - CorreCt Answers -Rephrase sentences the
client does not understand

110
...
The rationale for this
nursing action is which of the following?
A
...
Decreases the level of anxiety
C
...
Facilitates deep breathing - CorreCt Answers -Facilitates deep breathing

111
...
Which of the following
instructions should the nurse include?
A
...
Place an amber teething necklace on your child before bedtime
C
...
Apply a teething product containing benzocaine to your child's gums
before bedtime - CorreCt Answers -Administer acetaminophen drops to
your child before bedtime

112
...
Which of the following foods should the nurse
recommend?
A
...
Egg whites
C
...
Broiled lobster - CorreCt Answers -Egg Whites

113
...
Which
of the following actions should the nurse take?
A
...
Place broken glass in a wastebasket
C
...
Place lancets in a puncture-proof container - CorreCt Answers -Place
lancets in a puncture proof container

114
...
Which of the following information
should the nurse include in the teaching?
A
...
Place enough formula for 12 hr in the feeding container
C
...
Flush the tube with 30 mL of water between feedings - CorreCt Answers
-Allow the infant to suck on a pacifier during feedings
115
...
The nurse finds that the water seal is no longer tidaling
...
An air leak noted at the insertion site
B
...
Water needs to be added to the suction-control chamber
D
...
A nurse is assessing a client who has pericarditis
...
Dependent edema
B
...
Paradoxical pulse
D
...
A nurse is assessing a client 1 week after a successful bone marrow
transplant
...
The
nurse should recognize this desquamation as an indication of which of the
following complications?
A
...
Veno-occlusive disease
C
...
Pancytopenia - CorreCt Answers -Graft-versus-host disease

118
...
In the immediate postprocedure period, which of the
following is the priority nursing action?
A
...
Checking for orthostatic hypotension
C
...
Immobilizing the affect extremity - CorreCt Answers -Immobilizing the
affected extremity

119
...
Which of the following is appropriate to include in the
teaching?
A
...
Limit fluid intake to 40 oz/day
C
...
Avoid foods that have high levels of oxalates - CorreCt Answers -Restrict
dietary calcium intake

120
...
Which of the following clients
should the charge nurse assign to a nurse who is not pregnant?
A
...
A 20 year old client who is HIV positive
C
...
An 80 year old client who has alcoholic pancreatitis and is being treated
for impetigo - CorreCt Answers -A 60 year old client who is recovering from
shingles

121
...

Which of the following statements should the nurse include in the
teaching?
(Select all that apply)
A
...
A client who signs an informed consent form should understand the
treatment plan
C
...
The nurse should disclose the purpose of the treatment before the client
signs the consent form
E
...
A nurse is preparing to insert an indwelling catheter for a female
client
...
Apply sterile gloves and place cleansing balls in antiseptic
solution
2
...
Lubricate the catheter and place fenestrated drape over perineum
4
...
Insert the catheter until a flow of urine begins

123
...
Which of the following ethical principles is the
nurse demonstrating?
A
...
Autonomy
C
...
Veracity - CorreCt Answers -Justice

124
...
4 mEq/L
...
Hypotension
B
...
Muscle cramps
D
...
A nurse is reviewing the medical record of a client who has a new
prescription for gentamicin
...
Captropril
B
...
Furosemide
D
...
A nurse is preparing to administer 2
...
Which of the following is the safest site
for the nurse to use?
A
...
Dorsogluteal
C
...
Rectus femoris - CorreCt Answers -Ventrogluteal

127
...
Which of the
following clients should the nurse identify as the highest priority to receive
care?
A
...
A client who has an open skull fracture and is unresponsive
C
...
A client who has a fracture of the femur - CorreCt Answers -A client who
has a traumatic arm amputation

128
...
Which of the following clients
should the nurse assess first?
A
...
A client who has abdominal pain and is vomiting coffee-ground emesis
C
...
A client who had an open cholecystectomy and has green drainage from
the T-tube - CorreCt Answers -A client who has abdominal pain and is
vomiting coffee-ground emesis

129
...
Which of the following agents
should the nurse include in the teaching?
A
...
Isopropyl alcohol
C
...
Chlorhexidine - CorreCt Answers -Chlorine Bleach

130
...

Which of the following actions should the nurse include in the plan of care?
A
...
Provide high-calorie nutritional supplements
C
...
Allow the client to choose her clothes independently - CorreCt Answers Provide high-calorie nutritional supplements

131
...
Which of the
following prescriptions correct documentation?
A
...
4 mg IV stat
B
...
0 mg IV PRN every 6 hr
C
...
Enoxaparin 30 mg SC every 12 hr - CorreCt Answers -Enoxaparin 30 mg
SC every 12 hr

132
...
Which of the following
actions should the nurse take first?
A
...
Irrigate the wound with 0
...
Apply skin preparation to wound edges
D
...
A nurse is assessing a client who is gravida 2, para 1
...

The nurse should decrease the infusion rate for which of the following
findings?
A
...
Cervix is dilating at 1 cm every 4 hr
C
...
Contractions occur every 90 seconds - CorreCt Answers -Contractions
occur every 90 seocnds

134
...
The nurse should identify that these
findings are potential manifestations of which of the following?
A
...
Opioid intoxication
C
...
Alcohol withdrawal - CorreCt Answers -Opioid intoxication

135
...
After
receiving a change of shift report, which of the following clients should the
nurse assess first?
A
...
A client who is 1 day postpartum and has not voided in 8 hr
C
...
A client who is 4 days postpartum and has lochia serosa - CorreCt
Answers -A client who is 3 days postpartum and has not had a bowel
movement since prior to admission

136
...
Which of the following clients should
the nurse assess first?
A
...
A client who is 3 days postoperative colectomy with a large, loose melena
stool
C
...
A client who is coughing up pink-tinged sputum following a
bronchoscopy and lung biopsy 1 hr ago - CorreCt Answers -A client who is
coughing up pink-tinged sputum following a bronchoscopy and lung biopsy
1 hr ago

137
...
Which of the following statements should the
nurse manager include in the teaching?
A
...
Do not use a leading zero prior to a decimal point
C
...
Use the abbreviation QOD when indicating every other day - CorreCt
Answers -Include the complete name of the medication morphine sulfate

138
...
The provider writes a
prescription to initiate an IV infusion of Ringer's lactate at 150 mL per hr
...
Apply oxygen at 3 L/min per nasal cannula
B
...
Flush the catheter with sterile water
D
...
A nurse is planning care for a newly admitted client
...
Initiate an IV access for the client
B
...
Send the client to radiology for a CT scan
D
...
A community health nurse is performing a vision screening on a 4
month old infant
...
The infant's eyes turn toward the light
B
...
The infant's eyes remain focused toward the floor
D
...
A nurse is monitoring a client during an IV urography procedure
...
Metallic taste in mouth
B
...
Feeling flushed and warm
D
...
A nurse is reviewing the history and physical of a client who has right
ventricular heart failure
...
Creptius
B
...
Hepatosplenomegaly
D
...
A nurse is teaching a client and their family about home hospice care
...
Hospice care improves quality of life through palliative care
B
...
Hospice care is intended to postpone death
D
...
A nurse is preparing to administer eye drops to a client
...
Have the client tilt her head slightly so that the medication enters the
nasolacrimal duct
B
...
Use aseptic technique and drop the medication into the conjunctival sac
D
...
A nurse suspects another nurse is chemically impaired during their
shift
...
Report to the nurse manager
B
...
Assume care of the nurse's assigned clients
D
...
A nurse is providing teaching to an adolescent client who has cystic
fibrosis and has a prescription for pancrelipase
...
Take on an empty stomach
B
...
Take 1 hr after meals
D
...
A nurse manager is presenting information to the nursing staff
regarding the appropriate use of client restraints
...
The provider should renew the prescription for restraints every 48 hr
B
...
The nurse should tie the restraints using a square knot
D
...
The provider's prescription should include the type of restraint to use CorreCt Answers -Answer: B, D, E

148
...
Which of the following actions should the nurse
take?

A
...
Ask the client to verify the surgical site
C
...
Raise the side rails on the bed - CorreCt Answers -Raise the side rails on
the bed

149
...
Which of the following
instructions should the nurse include?
A
...
Use only ultra-thin diapers applied over the straps
C
...
Gently massage the skin under the straps once per day - CorreCt
Answers -Gently massage the skin under the straps once per day

150
...

Which of the following information should the nurse include?
A
...
A client who has a history of MRSA can develop immunity to the
infection
C
...
A client who has a history of MRSA can still transmit the infection CorreCt Answers -A client who has a history of MRSA can still transmit the
infection

151
...
The purpose
of which of the following is to generate new ideas to address the public
health concern?
A
...
A community-wide program
C
...
Personal discussions with clients - CorreCt Answers -A brainstorming
session with nurses

152
...
Which of the
following laboratory findings indicates hypervolemia?
A
...
Urine specific gravity 1
...
Serum sodium 138 mEq/L
D
...
001

153
...
Which of the following information should the
nurse include in the teaching?
A
...
Apply petroleum jelly to the nostrils prior to working in the field
C
...
Take a hot shower 1 hr after finishing work - CorreCt Answers -Change
clothes after working in the field

154
...
Which of the
following actions should the nurse take?
A
...
Implement a low-carbohydrate diet
C
...
Place warm compresses on area of pruritus - CorreCt Answers -Monitor
for abdominal ascites

155
...
The nurse should recognize that the teaching has been effective
when the client states,
A
...
My stoma will drain liquid fluid continuously
C
...
I will ensure that my medications are enteric coated - CorreCt Answers My stoma will drain liquid fluid continuously

156
...
Which of the following
actions should the nurse include in the plan?
A
...
Compare blood pressure in both arms every 2 hr
C
...
Encourage the client to restrict movement of the left arm - CorreCt
Answers -Auscultate the client's left arm for a bruit every 4 hr

157
...
Prior to administering the first dose, which of the following
laboratory values should the nurse evaluate?
A
...
Total cholesterol
C
...
Hemoglobin - CorreCt Answers -Thyroid hormones

158
...

Which of the following findings indicates the treatment is effective?
A
...
Oliguria
C
...
Capillary refill 4 seconds - CorreCt Answers -Flat anterior fontanel

159
...
Which of the following
clients should the nurse assess first?
A
...
A client who has an arteriovenous fistula that vibrates when palpated
C
...
A client who has chronic kidney disease with cloudy dialysate outflow CorreCt Answers -A client who has chronic kidney disease with cloudy
dialysate outflow

160
...
Which of the following client

statements should indicate to the nurse that the treatment has been
effective?
A
...
I was able to sit on a park bench for 30 minutes
C
...
I had a panic attack when driving by the grocery store - CorreCt Answers
-I was able to sit on a park bench for 30 minutes

161
...
Which of the following findings requires interventions by the
nurse?
A
...
Tidaling with spontaneous respirations
C
...
Drainage collection chamber is one-third full - CorreCt Answers Drainage collection chamber is one third full

162
...
Which of the following
actions should the nurse perform?
A
...
9% sodium chloride IV
B
...
Decrease the infusion rate to 75 mL/hr
D
...
9%
sodium chloride IV

163
...
Which of the following findings requires immediate intervention by
the nurse?
A
...
The client is lying in a supine position
C
...
The enteral feeding bag and tubing are not dated - CorreCt Answers -The
gastric residual volume is 250 mL following 2 hr of infusion

165
...
Identify where the
nurse should place the diaphragm of the stethoscope to best hear the
closing of the aortic heart valve
...
A nurse is performing change of shift assessments for four clients
...
A client who has gastroenteritis and is lethargic and confused
B
...
A client who has sickle cell anemia and reports pain 15 minutes after
receiving oral analgesic
D
...
A nurse on a labor and delivery unit is assessing four newly admitted
clients
...
A client who is at 38 weeks of gestation and reports irregular uterine
contractions
B
...

C
...
A client who is at 36 weeks of gestation and reports decreased fetal
movement for 2 days - CorreCt Answers -A client who is at 36 weeks of
gestation and reports decreased fetal movement for 2 days

168
...
For which of
the following diseases should the nurse implement droplet precautions?
A
...
Vancomycin-resistant enterococcus
C
...
Rotavirus - CorreCt Answers -Pertussis

169
...
The nurse should identify which of
the following allergies as a contraindication for the client to undergo a
thyroid scan?
A
...
Latex
C
...
Iodine - CorreCt Answers -Iodine

170
...
When determining what action to take, the nurse should recognize
that which of the following ethical principles should be applied?
A
...
Paternalism
C
...
Veracity - CorreCt Answers -Veracity

171
...
Which of the following statements by the client
indicates that the teaching has been effective?
A
...
I can play softball with my family in 3 weeks
C
...
I will go to my cardiologist's office when the battery needs to be changed
- CorreCt Answers -I will go to my cardiologist's office when the battery
needs to be changed

171
...
Which
of the following actions by the client requires the nurse to intervene?
A
...
Asking the father to change the newborn's diaper
C
...
Requesting the nurse take the newborn to the nursery so she can rest CorreCt Answers -Viewing the newborn's actions to be uncooperative

172
...
The
nurse should identify which of the following findings as an indication to
remove the restraints?
A
...
The client apologizes for their aggressive behavior
C
...
The client maintains eye contact while talking with the nurse - CorreCt
Answers -The client apologizes for their aggressive behavior

173
...
After confirming
compatibility, which of the following actions should the nurse take?
A
...
Occlude the IV tubing above the injection port
C
...
Flush the IV tubing with a heparinized solution - CorreCt Answers Occlude the IV tubing above the injection port

174
...
When reviewing the client's medical history, the
nurse should recognize which of the following diagnoses as a
contraindication to the administration of methylergonovine?
A
...
Hypertension
C
...
Hepatitis B - CorreCt Answers -Hypertension

175
...
The client is scheduled to have the morning dose at 0700
...
0900
B
...
1300
D

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