KAPLAN PREDICTOR A, B, & C – 2025 COMPLETE NCLEX PRACTICE EXAMS, 150

QUESTIONS EACH– WITH MOST TESTED QUESTIONS WITH VERIFIED A+

ANSWERS
Overview: Kaplan Predictor A, B, & C – 2025 NCLEX Practice Exams

The Kaplan Predictor Exams A, B, and C are powerful tools used by nursing programs and students to
gauge NCLEX-RN readiness. The 2025 updated versions reflect the latest NCLEX test plan, including
clinical judgment model alignment, and are designed to simulate the actual exam in both format and
difficulty.

What’s Included:

Each predictor (A, B, and C) contains:

• 150 NCLEX-style questions per form

• Most-tested high-yield topics based on current exam trends

• Select-all-that-apply (SATA), priority setting, delegation, and clinical scenario-based questions

• Detailed rationales for each correct answer to enhance understanding

• Verified A+ graded answers used by top-performing students

Key Content Areas:

• Pharmacology & Medication Administration

• Medical-Surgical Nursing (Cardiac, Respiratory, Neuro, GI, etc.)

• Maternal-Newborn & Pediatric Nursing

• Mental Health & Therapeutic Communication

• Infection Control & Patient Safety

• Priority, Delegation, and Time Management

• Health Promotion & Maintenance

• Physiological Adaptation

Purpose & Use:

• Predicts likelihood of passing the NCLEX on the first attempt

• Identifies knowledge gaps and helps focus review efforts

 • Often used as a graduation requirement or part of a final NCLEX prep course

Why It Matters:

• Kaplan Predictor Exams are data-driven tools used by nursing schools to track readiness

• A predictor score above 60–65% usually correlates with a high chance of NCLEX success

• These forms mimic the real test experience, boosting confidence and competence

PRACTICE A

The nurse shows a teenager how to use a metered dose inhaler of ipratropium (Atrovent). Which
statement if made by the client to the nurse, indicates teaching is effective? - ANSWER****"I should
use this medicine to prevent asthma attacks."

An older client is scheduled for a magnetic resonance imaging MRI procedure. Which of the following
statements, if made by the client to the nurse, should be reported to the technician before the test? -
ANSWER****I had a knee replacement 5 years ago

The nurse makes the following observations of a 6 hour old newborn: axillary temperature 96.4 F (35.8
C), apical pulse 148, respirations irregular at 48/minute, black sticky stool, blood glucose 60mg/dL. It is
most important for the nurse to take which action? - ANSWER****Wrap the newborn in a warmed
blanket

A client is returned to the unit at 10AM after laparoscopic gallbladder surgery. The nurse plans to get
the patient out of bed for the first time at 4PM. It is MOST important for the nurse to take which of the
following actions? - ANSWER****Offer pain medication to the patient at 3:30 pm.

OLD ANSWER: Turn the pt from side to side at 2 PM

The activity therapy staff takes a group of psychiatric patients on a trip to the zoo. The nurse should
intervene with which of the following patients before their departure? - ANSWER****A 38 year old
female who is receiving chlorpromazine (Thorazine) and is wearing a sundress without a hat or glasses
A patient experiences skin eruptions due to an allergic reaction to a medication. The nurse
demonstrates the BEST documentation with which of the following? - ANSWER****"Multiple red welts
noted over trunk and both arms. Patient states that welts itch"

An older client diagnosed with emphysema is admitted to the psychiatric unit for treatment of bipolar
disorder. The client receives oxygen per nasal cannula. The client expresses concern to the nurse that
someone will come in and change the amount of oxygen the client is receiving. INITIALLY, the nurse
should take which of the following actions? - ANSWER****Place a sign above the patients bed stating
that the oxygen level is not to be changed.

A teenager has a positive home pregnancy test and comes to the prenatal clinic. The girl is uncertain of
the date of her last menstrual period. The nurse palpates the uterine fundus midway between the
symphysis pubis and the umbilicus. Which statement by the nurse is BEST? - ANSWER****"You are 16
weeks pregnant. Lets talk about what that means."

A client is admitted to the psychiatric unit with complaints of fatigue, inability to concentrate, lack of
appetite, and repetitive thoughts. The client is reluctant to take the prescribed medications, fearing that
they are harmful. After the nurse gives the client the medication, the nurse should take which of the
following actions? - ANSWER****Instruct the client to open her mouth and move her tongue up and
down and to each side while the nurse looks inside

The nurse assesses a patient 72 hours after a total joint replacement of the right hip. Which finding
requires an intervention by the nurse? - ANSWER****The patients legs are internally rotated

A client newly diagnosed with Meniere's disease plans a trip to an amusement park with the family. The
client asks the clinic nurse which of the following rides is best. The nurse should suggest which of the
following rides? - ANSWER****Train

. A client is discharged from the hospital after coronary bypass (CABG) surgery 3 days ago. During
discharge teaching, the client asks the nurse "When can I resume sexual intercourse with my wife?" it is
best for the nurse to make which of the following statements? - ANSWER****You can resume sexual
activity when you are able to walk one block without chest pain or discomfort

A woman complains to the nurse about the care provided to her husband by the nursing staff the
previous night. Initially, the nurse should take which of the following actions - ANSWER****Ask the
wife to voice her expectations about a solution to the problem
A patient is restrained bodily by the nursing team. The hands of the nurse assigned to hold down the
patients leg should be placed in which of the following positions? - ANSWER****One hand directly
above the patient's knee and the other hand directly above the patient's ankle

The nurse in the community mental health center works with a client who is diagnosed with depression.
Cognitive therapy is initiated. The nurse should take which of the following actions? -
ANSWER****Help the client to identify the source of his depression

The nurse plans to perform a physical assessment of a young adult who has been deaf since birth.
Although the client indicates using sign language, no interpreter is available. The nurse should take
which action? - ANSWER****Write out each question, and ask the client to write out each answer

A patient received morphine 4 mg IV 2 hours ago for the complaints of postoperative pain. The patient
turns on the call light and tells the nurse he has to go to the bathroom. The patient has bathroom
privileges. The nurse should take which of the following actions? - ANSWER****Ask the patient to sit
on the side of the bed before proceeding to the bathroom

The nurse cares for a patient on the psychiatric unit with a history of drug use and poor impulse control.
After the patient's mother visits, the patient begins pacing rapidly, with arms swinging, and kicking at
chair legs. The nurse should approach the patient and take which of the following actions? -
ANSWER****Stand facing the patient with legs apart, knees locked, and weight on back leg

The nurse observes the nursing assistant giving morning care to an elderly client who has an area of
warm, reddened skin on the sacrum that does not blanch with pressure. Which action by the nursing
assistant requires an intervention by the nurse? - ANSWER****The aid firmly massages the reddened
area in a circular motion

The school nurse identifies several children who have food allergies. Which sequence should the nurse
teach the staff to follow if an allergic reaction is observed in a child? - ANSWER****Administer the
EpiPen, call 911, call the physician, call the parents

A client comes to the ER complaining of shortness of breath, fatigue, insomnia, and weight loss. The
client states that the client's company forced the client into early retirement. The client says that the
client has been sick ever since the client stopped working. The nurse should take which of the following
actions first? - ANSWER****Help the client see a connection between his symptoms and emotions,
while investigating each symptom.

The nurse teaches the woman diagnosed with type 1 diabetes who is pregnant for the first time. The
nurse teaches the client that as the pregnancy advances, the client may require which implementation?
- ANSWER****Increased amounts of insulin

The nurse cares for a patient after a colon resection. The patient has a Salem sump tube connected to
intermittent suction. The patient asks the nurse, "When will I be able to eat?" Which is the BEST
response by the nurse? - ANSWER****You will be started on clear liquids when we hear your stomach
make noises

The nurse supervises care provided for a client immediately after cardioversion. Which observation, if
made by the nurse, indicates the need for an intervention? - ANSWER****The oxygen the patient was
receiving before the procedure remains disconnected

The nurse cares for a client diagnosed with bursitis of the right shoulder. The nurse expects the client to
experience which of the following? - ANSWER****Pain with extension, flexion and internal rotation of
the right arm

The nurse supervises care provided by the nursing assistive personnel (NAP) to the older client in the
convalescent phase after a stroke. The nurse should intervene if which action is observed -
ANSWER****The client is supine with a pillow under the head

An older patient falls on the floor of the psychiatric unit. To determine the cause of the fall, it is MOST
important for the nurse to do which of the following? - ANSWER****Evaluate the floor where the
patient fell

The nurse instructs a prenatal class for first-time mothers. A group of mothers state they are afraid
because they have heard that babies often die in their sleep before their first birthday. The mothers ask
what they can do to prevent this. It is BEST for the nurse to make which of the following responses -
ANSWER****It's best to position the baby on its back or side in bed. There seems to be an increase in
this condition when babies are put to sleep on their stomach
A client attends a support group for incest survivors at the community mental health center. The client
tells the nurse, "I don't get it. People keep telling me I talk just like my father. He's the last person I'd
want to act like!" which response by the nurse is BEST? - ANSWER****Some people unconsciously
take on the characteristics of people who exert power over them

The family of a patient admitted to the psychiatric unit 3 days ago arrives for a visit carrying two
suitcases. The nurse informs the family that before they can proceed into the unit, the suitcases need to
be searched. The family asks why this needs to be done. Which is the BEST response by the nurse? -
ANSWER****"Things that you may not think of as being harmful may be used for harm by the patient"

The nurse asks the nursing assistant to obtain morning vital signs on several patients. It is best for the
nurse to make which of the following statements? - ANSWER****"Go check the vital signs for the
patient in rooms 321 and 322. Record your findings on this sheet and then return it to me"

The nurse reviews basic communication skills with a new group of nursing assistants. It is BEST for the
nurse to make which of the following statements? - ANSWER****"Nonverbal behavior is best
considered in combination with verbal communication"

The nurse cares for a woman at 7 months gestation diagnosed with preeclampsia. The client comes to
the outpatient clinic for her weekly checkup. The nurse is MOST concerned if which of the following is
observed - ANSWER****The client has 2+ pitting edema of her feet

A client with a history of arterial insufficiency is seen in the outpatient clinic. The client complains to the
nurse about frequent awakenings during the night because of a burning numbness in the lower
extremities. The nurse should advise the client to take which of the following actions? -
ANSWER****Place the legs in a dependent position

A 31-year-old female undergoes a tubal ligation. When the patient regains consciousness, the nurse
elevates the head of the bed 60 degrees. The patient says to the nurse, "I feel dizzy." The nurse should
take which of the following actions? - ANSWER****Lower the head of the bed slowly

The nurse completes the preoperative checklist for an elderly woman before a vaginal hysterectomy.
Which assessment would require an intervention by the nurse before the patient can go to the
operating room - ANSWER****The patients long hair pulled back using hairpins
The nurse suspects that a patient has autonomic dysreflexia (hyperreflexia). Which symptom supports
the nurse's conclusion? - ANSWER****The BP changes from 120/80 to 150/96

A newborn's birth weight is above the 95th percentile for estimated gestational age of 39 weeks. Which
term should the nurse use for documentation about this infant? - ANSWER****Term, LGA

The nurse completes an incident report after a complaint about nursing care from the family of a
patient. Which is the BEST statement for the nurse to make? - ANSWER****"Patients daughter stated
that she found her father lying in bed wet with urine when she arrived on 0730 on 6/2 and 6/3. Skin
intact on patients back, buttocks, and perineal areas. Discussed situation with nursing staff"

The nurse plans care for a patient with catatonic schizophrenia admitted to the inpatient psychiatric
unit. Which is the best goal for the nurse to establish for this patient INITIALLY? - ANSWER****The
patient will eat at mealtime with help from the nursing assistant

At the bedside of a patient, the nurse is preparing for insertion of a percutaneous intravenous catheter
(PICC) line. The patient holds out the left arm and says, "Please put it in this arm; I'm right handed."
Which response by the nurse is best? - ANSWER****The line needs to go into your right arm. It is
important for you to move your arm while the line is in place.

The nurse is caring for a client undergoing internal radiation therapy to treat cervical cancer. The client
is receiving Osmolite half-strength at 100 ml/h per Salem sump tube. Before hanging a new container of
Osmolite, the nurse aspirates the residual gastric contents. The nurse should take which of the following
actions? - ANSWER****Reinsert the solution into the Salem sump tube before starting the feeding

A patient diagnosed with schizophrenia approaches the nurse and reports a very sore throat, feeling
hot, and experiencing aches. It is flu season, and several patients and staff have been ill. Which is the
BEST action for the nurse to take? - ANSWER****Notify the physician so appropriate blood work can
be ordered

The nurse cares for a client scheduled to begin continuous ambulatory peritoneal dialysis (CAPD). Which
statement, if made by the client, is MOST important for the nurse to communicate to the physician? -
ANSWER****I know I have to be careful not to gain weight, but it is good to have my appetite back
The physician order phenytoin (Dilantin) 200 mg PO daily for a teenager. It is MOST important for the
nurse to include which of the following instructions when teaching the client - ANSWER****Visit your
dentist frequently

The nurse evaluates a patient in the emergency department for admission to the psychiatric unit. The
nurse is MOST concerned if the patient's history reveals which of the following? - ANSWER****Past
episodes of violence and alcohol ingestion

The nurse visits a 24-hour -old newborn at home. The nurse notes the newborns axillary temperature is
96.1 F (35.6 C). The nurse notes the newborn is pink with a small amount of jaundice on the nose. The
mother states that the newborn has been spitting up most feedings and has been "too sleepy to eat"
since early that morning. The newborn does not awake during the nurse's exam and has decreased
muscle tone. The nurse should prepare implementations for which medical diagnosis? -
ANSWER****Neonatal sepsis

The nurse expects a ventilator-perfusion (V/Q) scan to be ordered for which client? - ANSWER****A
client diagnosed with a PE

If reported in a 24 hour diet recall, which action is the best indication that the client understands the
teaching regarding a high-fiber diet? - ANSWER****The client sprinkles granola over vanilla ice cream
for dessert

The physician's office nurse checks the incision of a client 48 hours after a hernia repair. Which finding, if
observed by the nurse, is unexpected - ANSWER****The incision line is bright red

An agitated patient grabs another patient's hair from behind and begins to pull on it. INITIALLY, the
nurse should take which of the following actions? - ANSWER****Stabilize the patient's hand against
the other patient's head

The nurse cares for a client after abdominal surgery for a gunshot wound. The large abdominal dressing
is to be changed every 4 hours. While changing the dressing, the nurse notes that the area surrounding
the dressing is edematous and red. The nurse should take which of the following actions? -
ANSWER****Use Montgomery straps
A patient is admitted to the psychiatric unit with depression and suicidal ideation. Which action is MOST
important for the nurse to take? - ANSWER****Observe the patient every 15 minutes, and add several
unscheduled observations

A client diagnosed with malnutrition secondary to AIDS prepares for total parenteral nutrition (TPN).
The client says to the nurse "I know glucose is sugar. I can't see how giving me sugar is going to help
me." Which is the BEST response by the nurse? - ANSWER****This will give you enough calories so
that your body won't have to use protein stores for energy

The nurse identifies which of the following general environments as BEST for a client diagnosed with
depression? - ANSWER****An environment that offers structure and support

The nurse admits the woman in active labor to the birthing center. To monitor the client's uterine
contractions electronically, the nurse should place tocodynamometer (pressure transducer) in which
location? - ANSWER****Over the uterine fundus

The clinic nurse plans to use an interpreter to communicate with a client while performing a physical
assessment. Before beginning the examination, the nurse should instruct the interpreter to do which
action? - ANSWER****Explain everything said by the nurse to the client

. A woman who is HIV-positive just delivered a 6 lb, 13 oz baby. The woman expresses concern to the
nurse that her newborn baby will be HIV-positive. The nurse's response should be based on which of the
following? - ANSWER****Testing is inconclusive until 12 to 15 months of age because antibodies are
present in the newborns system

A client comes to the outpatient clinic for allergy shots. After administering the injection, the nurse
should take which of the following actions? - ANSWER****Instruct the client stay in the clinic waiting
room for at least 30 minutes

An older client is brought to the emergency department by the client's spouse. The client complains of
severe headache. The nurse notes the client has slurred speech, as well as facial droop and weak hand
grip on the left side. The nurse expects the physician to order which of the following tests? -
ANSWER****CT scan
The nurse administers digoxin (Lanoxin) and theophylline (Accurbron) to an elderly client through a
gastroscopy tube. After giving the medications, the nurse should take which of the following actions? -
ANSWER****Check the patient's respirations and apical heart rate

After several months of radiation therapy, a client with lung cancer refuses to continue with treatment.
It is MOST important for the nurse to take which of the following actions? - ANSWER****Ask the client
what it is about radiation therapy that makes him want to discontinue treatment

The nurse cares for a client immediately after a carotid endarterectomy. It is MOST important for the
nurse to have which of the following equipment at the bedside? - ANSWER****Trache set

The nurse cares for a client undergoing radiation therapy of the right breast and axilla after
lumpectomy. Which statement, if made by the client, indicates to the nurse that teaching is effective? -
ANSWER****I should wear a loose fitting bra made of 100% cotton to prevent irritation

The nurse cares for patient on the psychiatric unit. A patient becomes verbally abusive and begins
swinging arms and kicking anyone who approaches the patient. An order is obtained for mechanical
restraints. The nursing team is able to get the patient to the floor and under their physical control.
Before being lifted and taken to the patient's room for restraint application, the patient's body relaxes
and the patient says "I'm sorry. Ill cooperates. I'll walk to my room. Please don't hold me dow -
ANSWER****Tell the patient that he will be transported as planned

The nurse cares for a 3,000 gram newborn who receives ampicillin (Omnipen). The dosage is 100
mg/kg/day with doses divided, and it is administered every 12 hours. How many milligrams should the
nurse administer to the newborn every 12 hours? - ANSWER****150 mg

The registered nurse leads a patient care team that consists of one LPN/LVN and one nursing assistant. It
is considered appropriate for the RN to assign which of the following patient to the LPN/LVN? -
ANSWER****A 79 year old man diagnosed with Alzheimer's disease who is rubbing his chest and has a
respiratory rate of 22

The registered nurse delegates insertion of a Foley catheter to an LPN/LVN. Before the LPN/LVN begins
the procedure, it is MOST important for the registered nurse to take which of the following actions -
ANSWER****Ask the patient's permission for the LPN/LVN to perform the procedure
A nurse has lunch in the hospital cafeteria with a nursing assistant from the unit. The nurse asks how the
nursing assistant is doing, knowing that the nursing assistant is in nursing school, has three young
children, works 30 hours a week, and looks worried. The nursing assistant replies, "I'm okay, just
stressed out with finals." The BEST response by the nurse is which of the following? -
ANSWER****Sounds like you feel you're managing most things fine, but will be relieved when finals
are over

The nurse administers fentanyl 100 mcg IM to a patient after an appendectomy. After administering the
medication, is most important for the nurse to take which of the following actions -
ANSWER****Elevate the head of the patient's bed 30 to 45 degrees

After a patient receives naloxone hydrochloride (Narcan) 0.2 mg IV, which of the following actions is
essential for the nurse to perform? - ANSWER****Monitor the patient's rate of respirations

A client who is 5 feet 1 inch tall and 115 pounds recovers from an abdominal perineal resection. The
nurse notes that when the head of the bed is elevated, the client slips down in bed. The nurse should
take which of the following actions - ANSWER****Raise the knee gatch and the side rails, and place
the call light within reach

A 36 hour old newborn is receiving phototherapy. The infant's mother asks why this is being done.
Which response by the nurse is BEST? - ANSWER****This treatment converts bilirubin to a form that
can be removed from the body

The school nurse is demonstrating how to wash hands to a group of first grade children. The MOST
important behavior by the nurse is which of the following? - ANSWER****The school nurse rubs the
hands together briskly

The nurse cares for a client receiving enalapril (Vasotec) 40mg PO for several weeks. The client returns
to the outpatient clinic for a bimonthly visit. Which statement, if made by the client to the nurse,
indicates a problem with this medication? - ANSWER****" My bowel movements have become less
frequent and more difficult to pass."

The clinic nurse plans to perform a physical assessment of a 15-year-old girl. To initiate the interview,
the nurse should take which of the following actions? - ANSWER****Chat informally about the client's
friends, school, and family.
The nurse plans an in service on safety for LPN/ LVNs and nursing assistants. During the presentation, it
is MOST important for the nurse to make which of the following recommendations? - ANSWER****"
Carry your stethoscope curled up inside the pocket of your uniform or lab coat."

The nurse cares for a patient several hours after insertion of a central venous line. An IV of 0.9 NaCl is
infusing through the line at 50 cc/hour. The nurse notes that the patient is short of breath. After
notifying the physician, it is MOST important for the nurse to take which of the following actions? -
ANSWER****Elevate the head of the patient's bed to a semi-Fowler position.

A client diagnosed with type 1 diabetes comes to the outpatient clinic with complaints of pain of the
right leg and foot. If a diagnosis of peripheral arterial occlusion is made, which of the following
symptoms does the nurse expect to see? - ANSWER****The patient cannot distinguish between sharp
and dull pressure on his right leg

The nurse observes a student nurse prepare to insert a new peripheral catheter for a patient
immediately after a right mastectomy. Which site, if selected by the student nurse, requires an
intervention by the nurse? - ANSWER****A site close to the wrist joint

The family of a teenager recently diagnosed with allergic rhinitis moves into a new home. The clinic
nurse discusses with the parents the modifications they should make to the interior of their home.
Which statement, if made by the parents to the nurse, indicates teaching is effective? - ANSWER****"
We will use pull shades instead of curtains to cover the windows."

The school nurse performs health screening for scoliosis. The nurse should take which of the following
actions? - ANSWER****4. Observe for asymmetry of the scapula's, rib cage, and hips as the client
straightens from a bent position

The nurse cares for a client diagnosed with left-sided hemiplegia 2 days after a cerebrovascular accident
(CVA). It is most important for the nurse to take which of the following actions? - ANSWER****Elevate
the client's left arm and hand.

The nurse on an inpatient psychiatric unit cares for a patient diagnosed with depression. The nurse
contracts with the patient and spends half an hour a day with the patient and the patient becomes
increasingly responsive after 2 weeks. At this time, the patient's roommate begins to criticize the nurse
forcefully to anyone who will listen, including shouting out criticisms when the nurse is on duty. Which
action by the nurse is MOST appropriate? - ANSWER****Approach the roommate to discuss the
behavior regarding the nurse.

A patient is admitted to the hospital for a left lobectomy for a benign tumor. It is MOST important for
the nurse to include which of the following exercises in preoperative teaching with the patient? -
ANSWER****Range of motion exercises of the left arm and shoulder.

The patient is in the recovery room after a transurethral prostatectomy (TURP) under spinal anesthesia.
The nurse knows that the patient is fully recovered from the anesthesia if which of the following is
observed? - ANSWER****The patient can feel the nurse touching his feet.

The nurse cares for a patient just returned from the urology department after a needle biopsy of the left
kidney. It is MOST important for the nurse to take which of the following actions? -
ANSWER****Position the patient in a supine position

A father brings his adult child diagnosed with chronic schizophrenia back to the hospital for the fifth
admission in 2 years. The father asks the nurse, "When will this ever end? What did we do wrong?"
Which is the BEST response for the nurse to make? - ANSWER****" What you are feeling is very
common. You should join a support group of families that are in the same position."

While working with a team to restrain a physically combative patient, it is MOST important for the nurse
to remember which of the following? - ANSWER****Each team member should maintain an assigned
role throughout the restraining process.

. The nurse cares for a client diagnosed with type 1 diabetes. The client has experienced problems
related to gastrointestinal neuropathies for some time, with an increase in severity over the past 12
months. Which test, if ordered by the physician, should the nurse question? - ANSWER****Upper GI

The nurse cares for a patient recovering from a carotid endarterectomy. Which is an EXPECTED outcome
after this surgery? - ANSWER****The clients voice is low and raspy

The clinic nurse cares for a teacher receiving naproxen 500 mg BID for 3 weeks. The client reports to the
clinic nurse that she has had a fever and a rash on her trunk for a week. The skin is now flaking off,
leaving the underlying skin red and flaky. Which statement by the nurse is BEST? - ANSWER****This
may be a reaction to the medication you are taking. I'll notify your physician right away."

A patient is discharged after being treated for injuries sustained in an auto accident. The client has two
dressings, one on the left forearm and one on the right knee that need to be changed daily. Which
statement, if made by the patient, indicates to the nurse that further teaching is necessary? -
ANSWER****" I will use paper tape to secure the dressing"

The home health nurse explains the use of transcutaneous electrical nerve stimulation (TENS) to a client.
Which action, if performed by the client, indicates to the nurse that further teaching is necessary? -
ANSWER****The client places the electrodes on the side of the body opposite to the painful area

The nurse plans care for a patient with carpal tunnel syndrome. The nurse should question which of the
following orders? - ANSWER****Active ROM twice daily

The nurse in the same-day surgery department cares for an elderly client after a colonoscopy. The nurse
is MOST concerned if the nursing assistant reports which of the following findings 30 minutes after the
procedure? - ANSWER****"The client is complaining of lightheadedness and dizziness."

A client has received gavage feeding though a Levin tube for 2 weeks. This method of feeding is to be
discontinued. The nurse should take which of the following actions? - ANSWER****Flush the tube with
10 ml of normal saline before removing it.

The psychiatric nursing team consists of one registered nurse and three nursing assistants. Which
patient should be assigned to the registered nurse? - ANSWER****A 40-year-old man receiving
clozapine (Clozaril) who is complaining of a sore throat and fine hand tremors

A 9-month-old infant receives intramuscular injections every 12 hours. It is MOST important for the
nurse to take which of the following actions? - ANSWER****Administer one injection into the right
vastus lateralis and the next injection into the left vastus lateralis muscle

The nurse teaches the client about albuterol 2 inhalations every 6 hours by metered dose inhaler. Which
statement, if made by the client, indicates to the nurse that further teaching is necessary? -
ANSWER****"When I take the medicine I should inhale and then compress the container."
. A woman first noticed labor contractions at 4 A.M. The patient's membranes ruptured at 9:35 A.M.,
and the cervix was 10 cm dilated at 10:35 A.M. A healthy 7-lb, 6-oz infant boy was delivered at 11:15
A.M., and the placenta was expelled at 11:25 A.M. The nurse should record which of the following times
as the length of the third stage of labor? - ANSWER****10 minutes

The physician orders 1,000 mL of D5NS in 8 hours for an elderly client. The nurse hangs a 1-liter bag at 6
A.M. At 10 A.M., the bag has 400 mL remaining. Which action by the nurse is MOST appropriate? -
ANSWER****Decrease the rate to 100 ml/hr for 4 hours

The clinic nurse cares for a client diagnosed with irritable bowel syndrome. It is MOST important for the
nurse to include which of the following statements to the client? - ANSWER****"It would be helpful to
increase your intake of whole grains, raw fruits, and vegetables."

The nurse plans care for a patient diagnosed with schizophrenia who is withdrawn. Which patient
behavior does the nurse expect to observe? - ANSWER****The patient walks in the hall with the nurse
without talking.

A client is admitted to the emergency department with deep partial-thickness burns of the arms and
chest sustained in a house fire. The nurse notes that the client is very restless and anxious. Which action
should the nurse take FIRST? - ANSWER****Listen to breath sounds

The nurse talks with an upset patient on the psychiatric unit. The patient's anger appears to be
escalating. Which action should the nurse take? - ANSWER****Tell the patient that aggressive
behavior will not be tolerated

The nurse on a unit of the state hospital plans psychoeducational classes for chronic schizophrenics.
Most of the patients have been hospitalized for 20 years. Which classes should be planned FIRST by the
nurse? - ANSWER****Hygiene, communication skills, nutrition.

The postpartum nurse cares for a woman who is breastfeeding her first child. The client complains of
strong afterbirth pains while she nurses. Which statement, if made by the client to the nurse, indicates
that the client understands the cause of this discomfort? - ANSWER****"These pains show that my let-
down reflex is working.
. The nurse cares for the client after a fall from a ladder. While the client is waiting to be seen by the
physician, the nurse observes the client's spouse using a cloth to wipe clear fluid draining from the left
ear. Which statement, if made by the nurse to the spouse, is BEST? - ANSWER****"It is not a good idea
to wipe the ear, but let me know if you see it draining again.

A college student is brought to the emergency department after taking 200 mg of methylphenidate
(Ritalin). After gastric lavage is completed, it is MOST important for the nurse to take which of the
following actions? - ANSWER****Ask the patient to hold his breath as the tube is removed.

The clinic nurse evaluates a client for tendonitis of the elbow. Which statement, if made by the client,
indicates to the nurse a predisposition to this condition? - ANSWER****"I recently changed jobs and
now work as an apprentice carpenter."

The clinic nurse recommends a high-fiber diet for the older client reporting constipation. The client asks
the nurse how this will help. Which statement by the nurse is best? - ANSWER****"Fiber increases the
water content of your stool."

A newborn receives an Apgar score of 3 at 1 minute after birth. The nurse knows that a score of 3
indicates which of the following? - ANSWER****The newborn has a life-threatening anomaly

A young adult is brought to the emergency department for ingestion of 40 5-grain tablets of
acetaminophen (Tylenol). The patient's roommate reports that the patient took the pills 2 days ago after
a break up with a significant other, but the patient refused to go to the hospital at that time. Today the
roommate found the patient in bed, confused and gripping the upper abdominal area. The nurse
expects to see which of the following tests given the HIGHEST priority? - ANSWER****AST (SGOT) and
ALT (SGPT)

A client with a history of liver disease is brought to the hospital by her family. The family is frightened
because the client has become increasingly drowsy, gets disoriented and agitated, and sleeps during the
day and is awake at night. The nurse expects the physician to order which of the following? -
ANSWER****Lactulose (Chronulac) 200 g retention enema q 6 h

The nurse supervises care provided by a nursing assistant to a client who is demonstrating aggressive
behavior. The nurse should intervene if which of the following behaviors is observed? -
ANSWER****The nursing assistant demonstrates a friendly and conciliatory attitude.
A psychiatric patient diagnosed with an anxiety disorder is known to pace in the hall as a method of
calming himself down. After 20 minutes, the patient is usually able to engage in a one-to-one discussion
of his feelings. When the nurse sees the patient begin to pace, it is MOST important for the nurse to take
which of the following actions? - ANSWER****Allow the patient to pace, remaining available for
conversation and alert to the patient's anxiety level

An adolescent (gravida 1, para 0) is admitted to the labor unit for induction of labor. With the Pitocin
infusion at 20 milliunits/min, the patient's uterine contractions occur every 2 to 3 minutes and last 90
seconds. During a contraction, the fetal heart tones initially drop to 160/min, and then remain between
180 and 190/min. It is MOST important for the nurse to take which of the following actions? -
ANSWER****Stop the infusion of Pitocin

A 7 lb, 6 oz newborn is to receive vitamin K 9 (AquaMEPHYTON). It is MOST important for the nurse to
take which of the following actions? - ANSWER****Administer the medication IM into the infant's
vastus lateralis muscle using a 25- gauge needle.

The nurse asks the nursing assistant to provide A.M. care to a patient several days after a right total hip
replacement. The nursing assistant says, "I haven't bathed a patient with this problem before." It is BEST
for the nurse to take which of the following actions? - ANSWER****Review the bathing procedure for
this patient with the nursing assistant, and observe the bath

The nurse plans to perform a physical assessment of a teenager. It is MOST important for the nurse to
take which of the following actions? - ANSWER****Tell the client that everything she says will be held
in absolute confidence.

The nurse has a conversation with a newly admitted patient on the psychiatric unit. Several times during
their interaction the patient breaks eye contact and looks down at the floor. Which action by the nurse
is MOST appropriate? - ANSWER****Note the topics being discussed when the patient looks away.

The RN supervises the care provided by a nursing assistant to a patient being weaned from a mechanical
ventilator. It is MOST appropriate for the RN to make which of the following statements to the nursing
assistant? - ANSWER****"Count his respiratory rate every 15 minutes, and notify me if the rate is less
than 10 or greater than 30 breaths' per minute."
A patient is admitted to the psychiatric unit for treatment of bipolar disorder. During the admission
interview, when asked by the nurse the reason for the hospitalization, the patient responds, "I'm here
for tests on my heart." The nurse recognizes that the patient is most likely exhibiting which of the
following? - ANSWER****Denial

An LPN/LVN reports to the nurse that a client with a spinal cord injury at T2 is complaining of a severe
headache. The client's vital signs are BP 280/130, pulse 60, respirations 24. The nurse should take which
of the following actions FIRST? - ANSWER****Palpate the patients bladder

The clinic nurse obtains a history from a client complaining of gastrointestinal problems. If the client is
experiencing irritable bowel syndrome, which of the following symptoms are inconsistent with the
diagnosis? - ANSWER****Nausea and vomiting

A patient with a history of substance abuse and a poor work history is hospitalized for depression. The
patient tries to manipulate the staff members to get what the patient wants. Which approach by the
nurse is BEST? - ANSWER****Respond in a consistent manner to the patient's demands

.The nurse cares for a client with a Levin tube connected to intermittent low suction. At 0630 the night
nurse empties the suction container. At 1000 the nurse charts there is 65 mL of greenish drainage in the
suction container. At 1500 the nurse notes there is 210 mL of greenish drainage in the suction container.
Twice during the shift, the nurseirrigates the Levin tube with 30 mL of normal saline. Which is the
amount of drainage from the Levin tube for the 7 to 3 shift? - ANSWER****270 mL

A woman (gravida 7, para 6) is in active labor. The client's last cervical exam showed that she was 7 cm
dilated and 100% effaced and that the fetus was at 0 station. Which finding indicates to the nurse that
delivery is imminent? - ANSWER****There is increasing bloody show and complaints of rectal
pressure.

The outpatient nurse instructs a young adult diagnosed with primary syphilis. Which statement, if made
by the client, indicates to the nurse that teaching is effective? - ANSWER****"I will not have sexual
contact with my partner until my partner has been treated."

The clinic nurse teaches an elderly adult how to clean the ear mold of a behind-the-ear hearing aid.
Which statement, if made by the client to the nurse, indicates teaching is successful? - ANSWER****"I
will keep the ear mold connected to the battery device while I clean it."
A client is scheduled for a cardioversion in several hours. Which lab value indicates to the nurse that the
procedure may need to be postponed? - ANSWER****Digoxin level of 3 ng/ml.

The school nurse cares for a child diagnosed with a severe allergy to peanuts. The child's mother says to
the school nurse, "We like to try different ethnic foods." The nurse should suggest which of the
following as the safest cuisine for the family to sample? - ANSWER****Italian

A client undergoes a routine physical examination that reveals a severe hearing deficit in the left ear.
The nurse conducts a Weber test. If the client has a conductive loss, the nurse would expect the client to
report hearing the sound of the tuning fork in which of the following locations? - ANSWER****In the
left ear

A client comes to the emergency department with complaints of a sore throat, chills, and abdominal
pain. The spouse says the client became sick the day before but is worst today. The client has a
temperature of 102F (38.8C).The client's throat is red, and there is drainage from the oropharynx.
Initially, the nurse would expect the physician to order which of the following? - ANSWER****A throat
culture

A 79-year-old woman asks the clinic nurse which immunization she should have. It is BEST for the nurse
to make which of the following responses? - ANSWER****Influenza

A woman comes to the outpatient clinic because she believes that she has contracted genital herpes
(HSV-2) from her sexual partner. If the diagnosis of genital herpes were to be confirmed, the nurse
would expect to observe which of the following? - ANSWER****A cluster of painful blisters in her
genital area

The nurse administers succinylcholine (Anectine) to a patient before electroconvulsive treatment (ECT).
The nurse knows that the medication is given for which of the following reasons? -
ANSWER****Succinylcholine (Anectine) prevents the patient from having violent muscle contractions
and developing possible fractures during the treatment.

The nurse interviews a client diagnosed with schizophrenia and with diabetes with severe hypoglycemic
episodes. The client becomes increasingly restless, irritable, and belligerent. The client sees the food cart
containing remains from clients' lunches and immediately grabs and quickly eats food from the cart.
After several minutes the client's belligerence disappears. The nurse knows the client's belligerence is
caused by which of the following? - ANSWER****The client is hypoglycemic

The nurse observes the respiratory therapist remove condensation from a patient's ventilator tubing.
The nurse should intervene if which of the following is observed? - ANSWER****The respiratory
therapist returns the removed fluid to the heated water reservoir

A patient is admitted to the psychiatric unit complaining that the patient's neighbors, boss and
coworkers, and family are plotting against the patient. Which statement by the nurse is BEST? -
ANSWER****"Let me introduce you to all the patients on the unit."

A patient is scheduled for discharge 2 days after a colon resection. Which symptom, if observed by the
nurse, suggests the patient is experiencing a pulmonary embolism? - ANSWER****The patient
complains of tightness and pressure in his chest

A child who had abdominal surgery is scheduled to have the fourth postoperative dressing changed
during the day shift. The patient says to the nurse during morning care, "I hate these dressing changes. I
wish I didn't have to have them." Which response by the nurse is BEST? - ANSWER****"You sound
upset. What is it that you dislike about the dressing changes?

. A patient is observed to receive a soapsuds enema before surgery. The nurse delegates the procedure
to a nursing assistant who was transferred from another unit. While the nursing assistant performs the
procedure, the nurse should take which of the following actions? - ANSWER****Supervise the nursing
assistant while the enema is being given and help as necessary

A client has surgery for an obstructed bowel with creation of a colostomy. Six hours later, the client's
vital signs are BP 90/50, pulse 120 bpm, respirations 18/min, temperature 102.2F (39C). The nurse notes
that the client's muscles are rigid and the client's jaw is clenched. Which action should the nurse take
FIRST? - ANSWER****Notify the physician

A client with a history of alcohol and drug abuse and a severe seizure disorder attends a chemical
dependence day treatment program at the hospital. The nurse watches the client exit the elevator and
sit in a chair in the reception area. The client looks upset and dazed and says, "I had a seizure during
lunch." The nurse reminds the client that it is time to go for group. The client says, "Let me rest a
moment, and then I'll go." The nurse should take which of the following actions? - ANSWER****Take
the client's vital signs and sit with him quietly for several minutes
An elderly client returns to the room after a colostomy. Because the client has become confused and
repeatedly climbs over the side rails, the physician orders a Posey vest restraint. The nurse should take
which of the following actions? - ANSWER****Check the patient every 30 to 60 minutes and release
the restraint every 2 hours.

The triage nurse notices that the boyfriend of one of the emergency room patients has begun pacing
with clenched fists and swearing in an angry tone of voice. What action should the nurse take FIRST? -
ANSWER****Stay with the boyfriend and ask another nurse to alert the aggression management team

The nurse cares for a patient with two chest tubes inserted after a left lobectomy for removal of a
benign tumor. The patient asks the nurse why two chest tubes are required instead of just one. Which
response by the nurse is BEST? - ANSWER****"The upper tube is for air removal and the lower tube is
for fluid drainage."

The nurse cares for a client who is receiving amitriptyline (Elavil) 25 mg q A.M and 100 mg at HS. The
nurse understands that the medication schedule will accomplish which of the following? -
ANSWER****Reduce side effects experienced by the client

The nurse cares for a client diagnosed with superficial partial thickness burn. The nurse 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.

D.A client diagnosed with acute pelvic inflammatory disease. - ANSWER****A. A client diagnosed with
Cushing's Syndrome.

The nurse observes client care on a geriatric unit. The nurse should intervene in which situation?

a. A student nurse assist the client out of bed toward the clients strong side.

b. A student nurse assist the client to sit on the side of the bed by lifting the client's shoulders and
swinging the client's legs over the edge of the bed.

c. A student nurse assists the client to stand from a sitting position by grasping the client's elbows.
d. Two student nurses use a draw sheet to turn a client in - ANSWER****c. A student nurse assists the
client to stand from a sitting position by grasping the client's elbows.

The nurse evaluates the results of the client's purified protein derivative (PPD) 2 ½ days after the
injection. The nurse noted the induration is 4 mm. which action by the nurse is most appropriate?

a. Inform the client the results are negative

b. Obtain the names of the client's closest contacts.

c. Determine the HIV status of the client.

d. Wait and additional 24 hours to read the results. - ANSWER****a. Inform the client the results are
negative

The nurse cores for the client with a history of schizophrenia. The nurse expects to note which speech
pattern?

a. Repetition of the words used by the nurse.

b. Rapid, coherent conversation about unrelated topics.

c. Immediately answering questions appropriately.

d. Slow, purposeful answers to the nurses questions. - ANSWER****a. Repetition of the words used by
the nurse.

The nurse cares for a 6-month-old infant. The parents report that the infant had severe 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. Depresses anterior fontanel.

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 at

1200, and the nurse proceeds to administer hydromorphone at 1615. After discovering the error, 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 - ANSWER****d. "Hydromorphone given at 1615; health care provider notified.
B/P122/80,RR16."

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. Antihypertensive medications.

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 clients in a public place. -
ANSWER****c. Inform the employees about patient confidentiality and the client's right to privacy.

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 if which 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 - ANSWER****c. 480 ml

1 oz=30 ml; 60 oz*8= 480 ml

The nurse and LPN/LVN care for clients on a medical-surgical unit. The RN should delegate which activity
to the LPN/LVN?

a. Follow up on the client's report of chest and back itching two hours after starting a patient 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 prior to administration of
streptokinase.

d. Take the blood pressure and heart rate before admin - ANSWER****d. Take the blood pressure and
heart rate before administration of enalapril.

The nurses care for the client diagnosed with tuberculosis. Before discontinuing airborne 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. No acid-fast bacteria are in the
sputum.

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 makes which 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 exam - ANSWER****b. I'm sorry to tell you we can't
have sexual relations

The nurse prepares the client diagnosed with myxedema for discharge. Which action should the nurse
teach related to body temperature?

a. "Alternate acetaminophen with ibuprofen 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. "Put on multiple
layers of clothes until you fell comfortably warm.

The nurse cares for clients in the labor and delivery unit. The nurse anticipates which client is a
candidate for induction of labor?

a. The client with the fetal face as the presenting part.

b. The client diagnosed with preeclampsia.

c. The client diagnosed with active herpes infection.

d. The client experiencing late decelerations. - ANSWER****b. The client diagnosed with preeclampsia

The nurse cares for the client diagnosed with HIV. The nurse determines which goal is MOST important?

a. Prevent Kaposi's sarcoma.

b. Prevent depression

c. Prevent infections.

d.Prevent social isolation. - ANSWER****c. Prevent infections.

The nurse educator presents an in-service on acyanotic heart disease. Which is the most common
symptom of this disorder that the nurse educator should include?

a. Severe retarded growth.

b. Clubbing of the fingers and toes.

c. Presence of an audible heart murmur.

d. Polycythemia. - ANSWER****c. Presence of an audible heart murmur.

The nurse provides care for the client diagnosed with pneumonia who has postural drainage 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. "I am coughing up more sputum."
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. Failure to follow
routine policy and procedures.

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. Puberty. - ANSWER****a. Active exercise

The nurse cares for the client receiving lactulose. The nurse determines the medication 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. The client is alert and
oriented to person, place and time.

The nurse cares for the three-year-old prior to a surgical procedure. Which behavior indicates that the
child is coping with preoperative preparation?

a. The child hops around the room pretending to be a bunny while the nurse attempts to obtain a blood
pressure reading.

b. The child talks about the picture of a nurse and client while coloring the picture using a number of
bright colored crayons.
c. The child sits quietly reading a story about a boy who is going to have surgery while the nurse r -
ANSWER****b. The child talks about the picture of a nurse and client while coloring the picture using a
number of bright colored crayons.

The nurse instructs the client after a total hip arthroplasty. The client will utilize which assistive devices
in the home? SATA

a. Wheelchair

b. A long-handled shoehorn.

c. A reaching device.

d. A raised toilet seat.

e. A trochanter roll.

f. A shower bench. - ANSWER****b. A long-handled shoehorn.

c. A reaching device.

d. A raised toilet seat.

f. A shower bench.

The client reports vomiting and diarrhea for three days. Which assessment finding does the nurse
anticipate?

a. Bradycardia

b. Decreased blood pressure.

c. Peripheral edema.

d. crackles. - ANSWER****b. Decreased blood pressure.

The nurse cares for the client in active labor. The health care provider orders an oxytocin infusion.
Which action should the nurse take FIRST after initiating the infusion?

a. Time and record the length and strength of the contractions.

b. Prepare the client for an emergency cesarean birth.

c. Check the client's perineum for bulging.

d. Monitor the fetal heart rate. - ANSWER****a. Time and record the length and strength of the
contractions.

The intensive care nurse cares for the client two hours after a myocardial infarction is 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. Relieve pain.

The home health nurse instructs the family how to "allergy-proof" their preschooler's bedroom. The
nurse determines teaching

is successful if which of the following 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.

d. There are no pictures hung on the walls. - ANSWER****d. There are no pictures hung on the walls.

The nurse cares for infants in the newborn nursery. Which observation requires the nurse to contact the
physician?

a. The Asian female, 12 hours old, has a large bluish area noted across the sacrum and left 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 born 6 hours ago.

d. The anterior fontanel of a Caucasian male born 28 hours ago is moderately firm and flat. -
ANSWER****c. Uneven skin folds are noted on a the upper legs of a Mexican-American female born 6
hours ago.

The nurse cares for the client diagnosed with partial thickness burns to the entirety of 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. 18%

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 every hour 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 c - ANSWER****a. "My Client should push the hips up from the
wheelchair for about 10 seconds every hour or so."

The home care nurse makes a visit to the client diagnosed with heart failure. The client reports having
difficulty sleeping at times. The nurse should take which action FIRST?

a. Recommend taking over-the-counter diphenhydramine (Benadryl)

b. Encourage a half hour of moderate exercise prior to going to bed.

c. Obtain a thorough sleep assessment history.

d. Instruct the client to nap during the day. - ANSWER****c. Obtain a thorough sleep assessment
history.

The nurse cares for the client admitted to the critical care unit. The nurse observes splinter hemorrhages
in the nails, painful nodules on the fingertips and splenomegaly. It is MOST important for the nurse to
take which action?

a. Determine if client can comply with home IV therapy.

b. Auscultate the precordium for murmurs. (ENDOCARDITIS)

c. Instruct the client about the importance of balancing rest and activity.

d. Encourage the client to perform oral hygiene twice a day. - ANSWER****b. Auscultate the
precordium for murmurs. (ENDOCARDITIS)

The nurse instructs the client about stable angina. The nurse determines teaching is effective if the
client makes which statement?
a. Angina pain usually feels like being stabbed with a knife

b. Each time I have angina, my heart is damaged.

c. My chest pain can occur if I overexert myself.

d. If I have chest pain, then I'm probably having another heart attack. - ANSWER****c. My chest pain
can occur if I overexert myself.

The nurse cares for the client in pain. Which factor is MOST important to determine if the client is a
candidate for patient controlled analgesia?

a. The client has a surgical procedure of 30 minutes.

b. Body mass index does not exceed 30 kg/m2

c. The clients has a history of chronic pain.

d. The client is mentally alert. - ANSWER****d. The client is mentally alert.

The nurse received report from the previous shift. Which client should the nurse see FIRST?

a. The client recently admitted from the operating room who is drowsy and requesting something for
pain.

b. The client recently diagnosed with asthma with an O2 saturation of 97%

c. The client scheduled for discharge later in the day and is reporting increased shortness of breath.

d. The client who had an open cholecystectomy 24 hours ago with a temperature of 100 degrees -
ANSWER****c. The client scheduled for discharge later in the day and is reporting increased shortness
of breath.

The nurse reviews the arterial blood gas (ABG) report. The PH is 7.50; CO2 is 40mm; HCO3 is 30 mm.
Which is the MOST important question to ask the client? Pg 234

a. Do you smoke?

b. Do you have a history of emphysema?

c. How long have you been vomiting?

d. do you take insulin for your diabetes? - ANSWER****c. How long have you been vomiting?
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 188/104 - ANSWER****c. Turn and reposition the
client diagnosed with quadriplegia.

The nurse cares for the client diagnosed with anorexia nervosa. The nurse should include 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. Observe client during and one hour
after each meal.

The nurse cares for the client diagnosed with obsessive-compulsive personality disorder (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. Doubts, fears, and indecisiveness

The nurse prepares to administer medications. Which medication cannot be given directly
intravenously?

a. 50%dextrose

b. Potassium chloride (KCI)

c. Furosemide (Lasix)

d. Calcium gluconate. - ANSWER****b. Potassium chloride (KCI)

The nurse cares for a client diagnosed with pancreatic cancer. When talking to the 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. I've been
feeling fine and didn't go to the doctor until my skin was kind of yellow.

The parent of an adolescent diagnosed with hemophilia calls the nurse to discuss the adolescent's desire
to participate in sports. Which activity should the nurse recommend?

a. Soccer

b. Gymnastics

c. Swimming

d. Snowboarding - ANSWER****c. Swimming

1. The nurse prepares to administer medications to the following clients. Which medication should the
nurse pass FIRST?

a. Cephalexin to the postoperative client with a white blood cell count (WBC of 9.5/mm3

b. Morphine to the postoperative client term-42 reporting pain at a 5 on a 0-10 scale.

c. Ipratropium to the newly-admitted client diagnosed with chronic obstructive pulmonary disease.

d. Warfarin tot eh client with a prothrombin (PT) time of 16 seconds and an international normalized
ratio - ANSWER****c. Ipratropium to the newly-admitted client diagnosed with chronic obstructive
pulmonary disease.

The nurse provides discharge instructions to the client with a tube after traditional cholecystectomy.
The nurse determines teaching is effective if the client makes which statement?

a. The tube can be used to administer stone dissolving medications.

b. This tube will stay in for 1-2 weeks and drainage will decrease.

c. If it is this with mucus or blood, I an irrigate the t-tube.

d. I should milk the tube every 4 hours and record the drainage. - ANSWER****b. This tube will stay in
for 1-2 weeks and drainage will decrease.
The nurse prepares to administer digoxin for the 5-year-old child. The nurse should withhold the drug
and contact the physician for which finding?

a. The one-time dose of furosemide is also due.

b. Child has not eaten in several hours.

c. The nurse notes pallor of the child's skin.

d. A apical heart rate of 88 assessed. - ANSWER****d. A apical heart rate of 88 assessed. (60 or less
adult, 90 or less children)

The nurse cares for the client with a chest tube. Immediately after the tube is removed, it is MOST
important for the nurse to take which action?

a. Cover the section site with a moist saline dressing.

b. Secure the insertion site with several steri-strips.

c. Assist the health care provider to close the insertion site with sutures.

d. Request a STAT portable chest X-ray. - ANSWER****d. Request a STAT portable chest X-ray.

The home care nurse cares for the client diagnosed with benign prostatic hyperplasia. The client reports
not voiding since the previous evening. Assessment reveals a 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. Obtain an order for a straight catheter.

The nurse assigns the nursing assistive personnel (NAP) to the mother who is first day postpartum
following a vaginal birth. Which tasks are appropriate for the nurse to delegate to the NAP? (SATA)

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. Help the mother to ambulate
shortly after delivery.

c. Assist the mother with changing the perineal pad.

Two days after a short leg cast was applied for a fractured tibia, the client reports new, 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. Contact the health care provider.

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. Contact information for a local support
group.

The nurse prepares the 3 year old for discharge after a tonsillectomy. The nurse recommends 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. Lemon-lime soft drink

The client receives enteral nutrition at 50 ml/hour due to dysphagia. Which nursing action 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. - ANSWER****d. Risk for aspiration

The charge nurse has received change-of-shift report on a medical-surgical unit. Which activity can be
delegated to an LPN/LVN? (SATA)

a. Transfuse platelets for a client.

b. Change a dressing on a client with a stage IV pressure ulcer.

c. Initiate discharge teaching for the client whose B/P was 88/64 an hour ago.

d. Obtain vital signs on a client whose BP was 88/64 an hour ago.

e. Irrigate an urinary catheter.

f. Administer water through a gastrostomy tube. - ANSWER****b. Change a dressing on a client with a
stage IV pressure ulcer.

d. Obtain vital signs on a client whose BP was 88/64 an hour ago.

e. Irrigate an urinary catheter.

f. Administer water through a gastrostomy tube.

The nurse presents information about misuse of medications to the senior citizen group. Which client
response indicates a safe medication practice?

a. It is okay to use someone else's medication if it is similar to my prescription.

b. If I miss a dose of medication, I should not double up on the next dose.

c. Combining prescribed medicines with other the counter ones is cost-saving.

d. Sometimes we have prescriptions from several doctors out of necessity. - ANSWER****b. If I miss a
dose of medication, I should not double up on the next dose.

The nurse cares for the client in the emergency department. The client's friends state the client inhaled
varnish remover and passed out. The nurse notices a rash around the client's nose and mouth, axillary
temperature 97.8 degrees, pulse 66, respiration 12, blood pressure 168/88, pulse oximetry 98%. Which
action should the nurse take FIRST?
a. Provide oxygen 2L per nasal cannula.

b. Evaluate pupillary response.

c. Listen to heart sounds

d. Place patient in supine position. - ANSWER****b. Evaluate pupillary response.

Increased Intracranial Pressure: opposite of shock; increase BP, decreased Pulse and Decreased
Respirations. Pupils don't respond.

Which indicates to the nurse that a 41-year-old woman who is 5'5'' tall is obese?

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. Body mass index is 31 kg/m2

More than 30, more than 25 overweight. Less than 19 underweight.

The nurse cares for the client reporting a burning sensation and itching of the right 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 abrasion - ANSWER****a. Conjunctivitis

The nurse cares for the infant diagnosed with hydrocephalus immediately after placement of a
ventriculoperitoneal (VP) shunt. The nurse should place the infant in which position?

a. High Fowler's Position

b. Supine lying on the non-operative side

c. Supine lying on the operative side

d. Elevated 30 degrees - ANSWER****b. Supine lying on the non-operative side

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 response by 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 - ANSWER****c. Convalescence is lengthy and people
often report fatigue for several months.

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 client home. 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. The courts determine how long the
client is hospitalized.

The nurse cares for the adolescent diagnosed with Hodgkin's lymphoma. The adolescent receives
nitrogen mustard, vincristine, procarbazine and prednisone. Which adverse effect of the drugs requires
early preparation of the adolescent?

a. Constipation

b. Retarded growth in height

c. Alopecia

d. Nausea - ANSWER****c. Alopecia

The home care nurse instructs the client receiving long-term prednisone therapy. Which information
should the nurse include?

a. There is an increased risk for developing infections.

b. There is a resistance to developing infections.

c. The client should follow a high-protein diet.

d. There are changes in fat distribution over several areas of the body. - ANSWER****d. There are
changes in fat distribution over several areas of the body

The nurse witnesses a co-worker put one of two narcotic tablets in the co-workers purse twice during
the shift. Which action should the nurse take?

a. Confront the co-worker

b. Consult other staff about observation

c. Inform the nursing supervisor

d. Write an incident report - ANSWER****c. Inform the nursing supervisor

The nurse cares for the client with a pacemaker. When monitoring pacemaker functions, which should
the nurse assess FIRST?

a. Incision site

b. Apical pulse

c. Blood pressure

d. Electrocardiogram (ECG) - ANSWER****d. Electrocardiogram (ECG)

The adolescent diagnosed with acute mania is started on lithium. Which behavior indicates to the nurse
the medication is effective?

a. Decreased euphoria and slower rate of speech noted.

b. Increased interest in sexual activity.

c. Improved appetite and stable weight.

d. Increased social interaction noted during meal times. - ANSWER****a. Decreased euphoria and
slower rate of speech noted.

The nurse suspects that the client with severe uterine bleeding is in the early stages of shock. Which is
the PRIORITY nursing action?

a. Apply super absorbent perineal pads.

b. Establish intravenous access.

c. Administer oxygen per nasal cannula.

d. Place the client in Trendelenburg position. - ANSWER****c. Administer oxygen per nasal cannula.

When providing respiratory care for the client with a tracheostomy, it is MOST important 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. Preoxygenate the client prior to
suctioning.

The nurse provides care to a client diagnosed with cirrhosis. Which is the BEST explanation 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. Decreased concentration of

plasma albumin.

With cirrhosis there is malnutrition, with malnutrition there is decreased albumin, with decreased
albumin there is edema.

Nurses working in hospital environments should follow which guideline related to effective 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. Wash for at least fifteen
seconds covering all surfaces

The nurse cares for the primigravida during the transition phase of labor. Which is 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. Provide comfort measures
including position changes.

The nurse cares for the client diagnosed with a hearing impairment. Which is a 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. Speak at a slightly slower pace.

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 response by the nurse is MOST
appropriate?

a. Allow the mother to recover from the fatigue of delivery and then bring the newborn 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.

d. Reinforce the health care pr - ANSWER****d. Reinforce the health care provider's explanation of
the defect and allow time for the mother to discuss her fears.

The nurse reviews a diet containing broiled catfish, baked green beans, a roll, a brownie, and tea. The
nurse identifies this diet is most appropriate for which condition?

a. Celiac disease.

b. Type 1 diabetes.

c. Acute pancreatitis.

d. Crohn's disease. - ANSWER****d. Crohn's disease.

The nurse cares for a toddler diagnosed with croup. The nurse notes the toddler's respiratory and heart
rates have increased significantly. Sub sternal and intercostal

retractions are pronounced, and the child is restless. Which action should the nurse take FIRST?

a. Suction the child's airway.

b. Contact the health care provider.

c. Percuss the child on the back.

d. Increase the oxygen flow rate. - ANSWER****b. Contact the health care provider.

The client reports dyspnea, sever chest pain, nausea, and increased anxiety. Which lab value would
cause the nurse to contact the physician?

a. Creatinine kinase (CK) 155 units/L.

b. Troponin T 0.9 ng/mL.

c. Low-density-lipoproteins (LDL) 175 mg/dL.

d. Total serum lipids 850 mg/dL. - ANSWER****b. Troponin T 0.9 ng/mL.

An adolescent undergoing hemodialysis tells the nurse, "My friends are all going on a big trip over spring
break and I can't go. I don't think they'll miss me much anyway." Which is the BEST response by the
nurse?

a. I would not worry about that. You can communicate with them while they are gone.

b. You must be disappointed. Describe what you are feeling right now.

c. I've been left out of things before; you'll feel better when the break is over. - ANSWER****b. You
must be disappointed. Describe what you are feeling right now.

The nurse cared for clients diagnosed with AIDS. The nurse recognizes which statement is 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. Protease inhibitors
affect cell replication and have been successful.
The nurse instructs the client about a lumbar puncture. In which position will the client be 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. Lateral recumbent position.

The nurse assists the client to obtain a sputum specimen. Which action should the nurse take 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. The nurse performs hand
hygiene and dons clean gloves

The nurse cares for a three-year-old child diagnosed with severe anemia. The nurse observes 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. Increased heart rate.

The nurse cares for a child following corrective surgery for tetralogy of Fallot. The nurse 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. Instruct
the child's parent about food allowed on a 2 gram sodium diet.
The nurse cares for a client diagnosed with pneumonia. The client receives intravenous antibiotic
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.

2. Encourage increased consumption of fruit juices.

3. Collect a stool sample for Clostridium Difficile.

4. Complete a diet history of the past 3 days. - ANSWER****3. Collect a stool sample for Clostridium
Difficile.

A nurse in the pediatric clinic receives a call from a parent stating, "it looks like my 10- year-old has
chickenpox, but my child had the immunization". Which response by the nurse is BEST

1. "You should keep the child home for the next week".

2. The child will need a booster vaccine once the vesicles have disappeared".

3. "If your child had the vaccination, it can't be chickenpox".

Giveaspirinevery4hoursforfeverordiscomfort". - ANSWER****1. "You should keep the child home for

the next week".

After receiving report from the evening shift charge nurse, which client should the nurse see FIRST?

1. A 69-year -old diagnosed with chronic obstructive pulmonary disease requesting a sleeping pill.

2. A 52-year old client diagnosed with pancreatitis reporting abdominal pain.

3. A 67-year old client diagnosed with pneumonia with a pulse oximeter reading of 88%

4. A 78 year old client diagnosed with coronary artery disease with a blood pressure of 155/88. -
ANSWER****3. A 67-year old client diagnosed with pneumonia with a pulse oximeter reading of 88%

SAO2 95-99%

A nurse in the oncology clinic receives messages from four clients. Which client should the nurse see
FIRST?

1. A client diagnosed with testicular cancer requests information about sperm banking prior to starting
chemotherapy.

2. A client diagnosed with non-Hodgkin's lymphoma reports facial swelling.

3. A client diagnosed with colorectal cancer receiving chemotherapy reports tingling in the fingers.

4. A client who had a radical neck dissection notices whitish patches in the mouth. - ANSWER****2. A
client diagnosed with non-Hodgkin's lymphoma reports facial swelling.

The nurse develops a plan of care for the client diagnosed with osteoporosis. Which is the best
description on the PRIORITY goal?

1. Maintenance of body weight.

2. Improved nutritional intake.

3. Knowledge of medication side effects.

4. Prevention of falls and accidents. - ANSWER****4. Prevention of falls and accidents.

The nurse teaches the mother of a 3-month-old infant. When planning accident prevention, 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. Crib rails will be kept in the
highest position.

The nurse determines which lunch menu is the BEST choice for a patient diagnosed with 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. Turkey on wheat
bread, carrot sticks, chocolate cake, 6 oz iced tea

LOW SODIUM DIET, WATER FOLLOWS SALT

The nurse obtains a health history for the school-age child diagnosed with asthma. It is most 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. "I live in a rural area".

The nurse cares for the client just admitted to the surgical unit from recovery after a total 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. Position the client with the legs
abducted.

ABDUCTION SPLINTER OR TWO PILLOWS BETWEEN LEGS

The nurse cares for the school-age child receiving phenytoin. The nurse should observe for 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. Gingival hyperplasia.

(phenytoin =Dilantin=anticonvulstant)

The nurse cares for the child diagnosed with cystic fibrosis. The nurse should intervene if the child is
eating which food?

1. Chili.

2. Roasted chicken tenders.

3. A vanilla milkshake.

4. Slice of watermelon. - ANSWER****3. A vanilla milkshake.

LOW FAT, HIGH PROTEIN, HIGH CARB AND CALORIES

The client diagnosed with type 1 diabetes reports to the nurse, "I feel really nervous and jittery 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. Determine the client's recent
dietary intake.

Question 93 is #1 - ANSWER****

Question 94 is #2 - ANSWER****

The nurse cares for the client diagnosed with bipolar disorder. The nurse determines which 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. - ANSWER****1. Relaxation exercises.

4. Scheduled rest periods.

5. Aerobic exercises.

6. Listening to soft music

The health department nurse cares for the client diagnosed with tuberculosis and positive 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. The director of the local homeless shelter. - ANSWER****3. Social worker from social services
department.

The adolescent tells the school nurse she is planning to start sexual relations with her boyfriend. Which
is the BEST response by the nurse?

1. "I can make a referral to a gynecologist for you".

2. "Have you discussed this decision with your parents?"

3. "Surely you understand I'll have to let your parents know".

4. "How do you plan on paying for contraceptives? - ANSWER****2. "Have you discussed this decision
with your parents?"

The nurse cares for the client after colostomy surgery. Eight hours after surgery, what observation
would the nurse expect?

1. A dusky-red appearance of the stoma.

2. Absence of any output from the colostomy.

3. Bright bloody drainage from the nasogastric tube.

4. Presence of hyperactive bowel sounds. - ANSWER****2. Absence of any output from the colostomy.

The nurse care for the clients in the Sleep Study Unit. The nurse recognizes which client is at GREATEST
risk for developing obstructive sleep apnea?

1. 30 year old male, works nightshift as a security guard.

2. 50 year old female, smokes two packs/day.

3. 60 year old male, 55 pounds over ideal weight.

4. 40 year old female, active alcoholic. - ANSWER****3. 60 year old male, 55 pounds over ideal weight.
The client after radical prostatectomy expresses concern related to ongoing urinary incontinence. Which
response by the nurse is BEST?

1. Have you been doing Kegel exercises?

2. It is important to anticipate leakage and stay close to a bathroom at all times.

3. Drinking more fluids with your meals will decrease the need to void.

4. Avoiding caffeine and alcohol may reduce bladder irritation. - ANSWER****1. Have you been doing
Kegel exercises?

The client reports severe lower back pain radiating down the left leg. The client identifies the pain as 9
on a 0-10 scale and states, "It feels like I've been stuck with a hot poker". Which order should the nurse
anticipate?

1. Opioid analgesic.

2. Nonsteroidal anti-inflammatory drugs.

3. Immunosupressant agent.

4. Topical nonopioid analgesic. - ANSWER****1. Opioid analgesic.

The nurse on the pediatric unit receives report from the previous shift. Which client should be seen
FIRST?

1. The 8 year old newly diagnosed with type 1 diabetes with a blood sugar of 285 mg/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 100.3 degrees F (37.9
degrees C).

4. The 10 year old with cerebral palsy with a newly placed enteral nutrition - ANSWER****1. The 8
year old newly diagnosed with type 1 diabetes with a blood sugar of 285 mg/dl.

The nurse instructs the client receiving enoxaparin (LOVENOX). Which client response indicates 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. I will inject the medication into the
far left or right side of my abdomen every day.
(ANTIDOTE: Protamine sulfate)

The nurse cares for the client receiving acyclovir. The nurse knows acyclovir is used to treat which
condition?

1. Herpes simplex.

2. Contact dermatitis.

3. Candidiasis.

4. Psoriasis. - ANSWER****1. Herpes simplex.

The nurse cares for the client diagnosed with spinal cord injury at the level of T1. The nurse notes the
client is flushed and sweating profusely. The client reports a headache and nausea. 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. Palpate the client's bladder.

ASSESS FIRST ;IPPA (she inspected and now palpate)

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. Prior to 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. Validate the baby has wet a diaper.

No PEE no K!!!!!!
The nurse cares for the client diagnosed with HIV. The client reports difficulty coping with the diagnosis.
The nurse encourages the client to take which action?

1. Attend church services weekly.

2. Obtain a prescription or an anti-depressant medication.

3. Keep a journal recording feelings.

4. Identify successful coping mechanisms used in the past. - ANSWER****4. Identify successful coping
mechanisms used in the past.

The nurse cares for a client scheduled for a magnetic resonance imaging (MRI) of the back. Which client
response required an intervention by the nurse?

1. I am allergic to shellfish and iodine.

2. I use nitroglycerin tablets for angina.

3. I had a total hip replacement three years ago.

4. I am on a blood thinner and bleed easily. - ANSWER****3. I had a total hip replacement three years
ago.

The nurse instructs the client diagnosed with vitamin B12 deficiency. The nurse recognizes teaching is
effective if the client chooses which menu?

1. Broiled chicken breast, white rice, green beans, and lemonade.

2. Liver and onions, macaroni and cheese, tossed salad, and milk.

3. Medium-rare beef steak, baked sweet potato, boiled carrots, and soda.

4. Baked pork chop, mashed potatoes, creamed corn, and tea. - ANSWER****2. Liver and onions,
macaroni and cheese, tossed salad, and milk.

The nurse cares for the client diagnosed with advanced cirrhosis. When the client raises both arms, the
nurse observes flapping tremors of the hands and wrists. What is the medical term used to describe
this?

1. Apraxia.

2. Caput medusa.

3. Fetor hepaticus.
4. Asterixis. - ANSWER****4. Asterixis.

The nurse cares for the client who returned from overseas having recently lost both lower limbs to a car
bomb. The nurse notes the client is increasingly irritable, is unable to

sleep well due to recurring nightmares, and seems hyper vigilant. The nurse recognizes these symptoms
are most likely indicative of which condition?

1. Obsessive compulsive disorder (OCD).

2. Bipolar disorder.

3. Regression.

4. Post-traumatic stress disorder (PTSD). - ANSWER****4. Post-traumatic stress disorder (PTSD).

The nurse cares for the client following a vegan diet. The nurse recognizes which meal selection 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. Bran flakes, soy milk, grapefruit and
tofu.

ONLY EATS VEGETABLE PRODUCTS.

The nurse assists the client to breastfeeding the baby for the first time. Which observation 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. Swallowing noises can be heard.
The community nurse instructs the client receiving isoniazid. The nurse is MOST concerned 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. I will limit my alcohol intake to 1 beer/day.

(alcohol increases risk for hepatotoxicity, wrong statement shouldn't drink)

At 1500, the nurse begins the infusion of packed red blood cells (PRBC's). The client asks 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. The transfusion will be completed by
1800

(infuse 3-4 hrs)

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 determines which injection site is MOST
appropriate?

1. Vastus lateralis.

2. Deltoid.

3. Ventrogluteal.

4. Abdomen. - ANSWER****1. Vastus lateralis.

The nurse plans a burn prevention program for older adults. What is the best description 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. Pots and pans on a stove.

Prior to administration of a cleansing enema, the nurse explains the procedure to the client. 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. I have
to lie on my right side while you put the solution in me.

(position on Left Sim's position to allow the solution to flow by gravity

The nurse cares for the adolescent diagnosed with asthma. Which is the MOST appropriate 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. There is a narrowing
of airways going to your lungs.

The nurse cares for the unconscious client after a motor vehicle accident. The nurse does 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.

4. Smell of cigarette smoke on the patient's clothes. - ANSWER****1. A rounded chest and clubbing of
nails.
The school nurse reviews bike safety concerns with elementary school children. Which statement
indicates to the nurse teaching is effective?

1. I know my bike is the right size because I can read the pedals.

2. I can ride in the street as long as I ride on the left hand side.

3. I will use a bike helmet and wear light colored clothing when I ride.

4. I will have to buy a horn if I want to ride at night. - ANSWER****3. I will use a bike helmet and wear
light colored clothing when I ride.

The nurse cares for the client on an NPO status. The client repeatedly asks the nurse for something to
drink. Which action by the nurse is MOST appropriate?

1. Frequently explain why fluids are restricted.

2. Offer several ice chips each time the client requests a drink.

3. Turn on the television or radio.

4. Provide oral hygiene care frequently. - ANSWER****4. Provide oral hygiene care frequently.

The nurse cares for the client after a near-drowning experience in the Atlantic Ocean. It is MOST
important for the nurse to monitor for which complication?

1. Hypernatremia.

2. Hypomagnesemia.

3. Hypocalcemia.

4. Hyperkalemia. - ANSWER****1. Hypernatremia.

The newly admitted client tells the nurse, "I have not had a good bowel movement in 10 days". It is
MOST important for the nurse to ask which question.

1. What types of food with fiber do you eat?

2. Have you had small amounts of liquid stool?

3. Do you notice a bad odor to your breath?

4. Are you having any nausea and vomiting? - ANSWER****2. Have you had small amounts of liquid
stool?
CAN BE OBSTRUCTION OR IMPACTION

The nursing instructor reviews electrolytes and discusses common causes for hypercalcemia. The
instructor determines teaching is effective when the student choose which as a common cause of
hypercalcemia?

1. Malnutrition.

2. Bone malignancy.

3. Hyperthyroidism.

4. Long-term use of furosemide. - ANSWER****2. Bone malignancy.

(the bone releases calcium into the bloodstream)

The nurse cares for the client after percutaneous transluminal coronary angioplasty (PTCA) with stent
placement. The nurse determines care is appropriate if which tasks are delegated to the nursing
assistive personnel (NAP)?

Select all that apply.

1. Remind the client to remain flat in bed.

2. Obtain vital signs every 15-30 minutes.

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 electroca - ANSWER****1. Remind the client to remain flat in bed.

2. Obtain vital signs every 15-30 minutes.

4. Provide the client with fluids to drink.

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 the nurse'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 calls Respiratory Th -
ANSWER****2. Place the client in high Fowler's position and auscultate the lungs.

The nurse receives a call from a client. The client reports having dark-colored bowel movement. 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. Determine if the client is taking ferrous
sulfate.

The nurse cares for the client diagnosed with type 2 diabetes and an infection in the left 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/h

4. T 99.2 F (37.3 C), P 88, R 18, BP 120/76 - ANSWER****3. Erythrocyte sedimentation rate (ESR) 28.2
mm/h

The nurse cares for the client diagnosed with advanced Parkinson's disease. Which activity is MOST
appropriate to decrease fatigue?

1. Establish a regular bed time.

2. Provide for morning and afternoon naps.

3. Avoid high carbohydrate foods.

4. Schedule alternating periods of rest and activity. - ANSWER****4. Schedule alternating periods of
rest and activity.

The client has a 2.5 centimeter abdominal aortic aneurysm (AAA) discovered on X-ray. The nurse
determines which goal is MOST appropriate for the client?

1. The client will report pain of no greater than "4" on a 0-10 scale.

2. The client will return for follow-up appointments every 6 months.

3. The client will verbalize understanding of perioperative nursing care.

4. The client will limit activities to bathing, eating, dressing, and toileting. - ANSWER****4. The client
will limit activities to bathing, eating, dressing, and toileting.

The nurse cares for the client diagnosed with diabetes insipidus. Which finding will the nurse expect to
observe?

1. Daily fluid intake of 1-2 liters.

2. Urine specific gravity of 1.050.

3. Daily urine output of 10 liter.

4. Serum sodium level of 120 mEq/L. - ANSWER****3. Daily urine output of 10 liter.

(Polyuria 2 to 24 L/day, low specific gravity 0.006,)

The nursing supervisor observes the staff nurse's ease and excellence in communicating with new
parents and family members. The supervisor recommends the staff nurse for the position teaching
childbirth classes. What component of leadership has the supervisor demonstrated?

1. Empowerment.

2. Charismatic leadership.

3. Compassionate leadership.

4. Shared governance. - ANSWER****1. Empowerment.

The nurse receives report for clients on a Woman's Health Unit. Which client should the nurse see
FIRST?

1. The client post bladder repair reports pain is not fully relieved by medication administered through
the PCA pump.

2. The client 6 hours after a right mastectomy reports the sheets under her torso feel wet.

3. The client 12 hours after abdominal hysterectomy with a pulse of 90 and B/P 130/88.

4. The client diagnosed with pelvic inflammatory disease with an oral temperature of 101.8 degrees -
ANSWER****2. The client 6 hours after a right mastectomy reports the sheets under her torso feel
wet.
The nurse instructs the client after a cataract extraction with a lens implant. The nurse determines
further teaching is necessary if the client makes which statement?

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. It's
okay to bend over and pick up my grandchild if I am wearing my eye shield.

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 pur - ANSWER****2. Place external uterine and fetal monitors on the
client's abdomen.

The client is scheduled for a pelvic ultrasound. Prior to the procedure it is MOST important 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. Instruct the client to drink several glasses of water.

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 while intoxicated and speeding. Which
is the MOST likely cause of the amnesia?
1. Repression.

2. Suppression.

3. Projection.

4. Dissociation. - ANSWER****4. Dissociation

The nurse teaches the parent of an infant after repair of cleft lip and palate. Which is the 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. Normal saline.

The nurse on a medical-surgical unit received report. Which clients should the nurse see 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 an alarm.

4. The client 12 hours after a laparoscopic cholecystectomy states, "My shoulder hurts". -
ANSWER****1. The client diagnosed with heart failure and dementia trying to get out of bed.

The nurse instructs an adolescent diagnosed with a sprained left ankle. Further teaching 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. I will put a
heating pad on my ankle as soon as I get home.

RICE: rest, ice, compression, elevation

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 help you.

4. These pills came straight from the pharmacy just like everyone else's. Why do - ANSWER****3. It
sounds like you are afraid that the staff might hurt you, this is a medication to help you.

The nurse teaches the client diagnosed with Addison's disease. What is MOST important 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. Take hormone replacement

therapy as prescribed.

144. The nurse identifies which client is at GREATEST risk for developing osteomyelitis?

1. A 75 year old client diagnosed with chronic lymphocytic leukemia with a positive wound culture
showing methicillin-resistant Staphylococcus aureus infection.

2. A 35 year old client with a history of smoking being treated for an inguinal hernia and is placed on a
nicotine patch.

3. An 82 year old client hospitalized for a compound fracture of the left femur treated with an open
reduction 48 hours ago.

4. - ANSWER****1. A 75 year old client diagnosed with chronic lymphocytic leukemia with a positive
wound culture showing methicillin-resistant Staphylococcus aureus infection.

The nurse prepared to administer buspirone 15 mg to the client. The nurse recognized this medication is
MOST appropriate for which client?

1. The 45 year old woman diagnosed with pancreatitis reporting nausea and vomiting.
2. The 27 year old woman diagnosed with panic attacks.

3. The 60 year old man diagnosed with coronary artery disease with a blood pressure of 172/94.

4. The 38 year old man diagnosed with schizophrenia reporting auditory hallucinations. -
ANSWER****2. The 27 year old woman diagnosed with panic attacks.

Antianxiety Med

The nurse records the following intake of the client during an 8 hour shift: ½ liter of oral bowel prep
solution (500 ml) 8 ounces of juice 1 oz = 30 ml; (240 ml)

4 tablespoons of medicine through a G-tube 1 tbsp= 15 ml; (60 ml)

2 cups of water 1 cup=8 oz= 16 oz; (480 ml)

0.9% sodium chloride at 125 ml/hour IV 125*8= (1000 ml) Record the patient's intake in milliliters (ML) -
ANSWER****2280 ML

The nurse cares for the unconscious client diagnosed with a closed head injury. There is no family
present. What is the MOST appropriate action for the nurse to take?

1. Wait until a family member is contacted before treating the client.

2. Request the attending health care provider to sign the consent form.

3. Begin treatment on the client under the doctrine of implied emergency consent.

4. Delegate the unit secretary to call every number listed on the client's cell phone. - ANSWER****3.
Begin treatment on the client under the doctrine of implied emergency consent.

The nurse and nursing assistive personnel (NAP) care for clients in the postpartum unit. The nurse
appropriately delegated which tasks to the NAP?

Select all that apply.

1. Document the amount of food intake at lunch.

2. Assist the father dress a newborn prior to a photograph.

3. Perform an intermittent bladder catheterization.

4. Speak to the health care provider about the results of a client's complete blood count.

5. Ambulate the mother after cesarean birth to the bathroom.

6. Obtain the vita - ANSWER****1. Document the amount of food intake at lunch.

2. Assist the father dress a newborn prior to a photograph.

5. Ambulate the mother after cesarean birth to the bathroom.

6. Obtain the vital signs on the client ready for discharge.

The nurse cares for the child diagnosed with a closed head injury. It is most important for 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. The child's response to the environment.

(level of consciousness)

The staff nurse asks for the goals of the Quality Assurance Committee. Which is an example 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. Survey documentation of follow-up
after administration of pain medication.

Which of these instructions should a nurse include in the teaching plan for a client who had removal of a
cataract in the left eye? - ANSWER****"Take the prescribed stool softener to avoid increasing
intraocular pressure."

A client vomits during a continuous nasogastric tube feeding. A nurse should stop the feeding and take
which of these actions? - ANSWER****Check the residual volume.
Which of these actions best demonstrates cultural sensitivity by a nurse?. - ANSWER****The nurse
asks clients about their beliefs and practices toward pregnancy.

Which of these manifestations should a nurse expect to observe in a 3-month-old infant who is
diagnosed with dehydration? - ANSWER****Tachycardia.

When assessing a client's risk of developing nosocomial infection, a nurse plans to determine potential
entry portals, which include: - ANSWER****the urinary meatus.

A client who is on the inpatient psychiatric unit has a history of violence. Which of these actions should a
nurse take if the client is agitated? - ANSWER****Encourage the client to verbalize feelings.

Which of these measures should a nurse include when planning care for a school-aged child during a
sickle cell crisis episode? - ANSWER****Providing pain relief.

Which of these instructions should a nurse include in the plan of care for a 32-week gestation client who
had an amniocentesis today? - ANSWER****"Call the clinic if you experience any abdominal cramps."

An adolescent has a nursing diagnosis of fatigue related to inadequate intake of iron-rich foods.
Selection of which of these lunches by the client indicates a correct understanding of foods high in iron
content? - ANSWER****Beefburger with cheese.

A client has been admitted with acute pancreatitis. Which of these laboratory test results supports this
diagnosis? - ANSWER****Elevated serum amylase level.

Which of these manifestations, if assessed in a client who is two-hours postoperative after abdominal
surgery, should a nurse report immediately? - ANSWER****Vomiting and a pulse rate of 106/minute.

Which of these observations of a student nurse's behavior while interacting with a client who is crying
indicates a correct understanding of therapeutic communication? - ANSWER****The student sits
quietly next to the client.
Which of these actions should a nurse take initially if a client who is diagnosed with diabetes mellitus
develops tremors and ataxia? - ANSWER****Measure the client's blood sugar level.

An elderly client is at increased risk of developing drug toxicity to prescribed medications due to
declining hepatic and renal functioning. Which of these strategies should a nurse plan to decrease this
risk? - ANSWER****Increasing the time interval between medication doses.

A client has persistent paranoid delusions that the food on the unit is poisoned. Which of these
measures should a nurse include in the client's care plan? - ANSWER****Allowing the client to eat
food from sealed containers.

Thrombophlebitis is a complication that may result due to surgery. Which of these actions should a
nurse take in the operating room to prevent this complication from occurring? - ANSWER****Apply
sequential compression devices.

When discussing weigh gain during pregnancy, a nurse should recommend that the total weight gain for
a pregnant client who is at ideal body weight for her height is: - ANSWER****25 to 35 pounds.

Which of these manifestations, if reported by a client who is 10-weeks-pregnant, supports the diagnosis
of ruptured tubal pregnancy. - ANSWER****Sharp unilateral abdominal pain.

Which of these assignments, if made by a nurse to a nursing assistant, indicates that the nurse needs
additional instructions regarding the principles of delegation? - ANSWER****"Please bathe the client
in room 10, administer a back rub, and then evaluate if the back rub eased the client's discomfort."

A client has the following order for regular insulin (Humulin R) on a sliding scale:

Blood sugar 150-180 mg: Give 2 units regular insulin

Blood sugar 181-200 mg: Give 4 units regular insulin

Blood sugar 201-220 mg: Give 6 units of regular insulin

Blood sugar above 220 mg: Call MD

At 11 A.M., a nurse obtains a finger stick glucose of 198 mg. The only syringe is a three milliliter one.
Regular insulin is available as 100 units per milliliter. How many milliliters should the nurse administer? -
ANSWER****0.04

Which of these nursing diagnosis is the priority for a client who is one-hour postoperative after
extensive abdominal surgery? - ANSWER****Risk for ineffective airway clearance.

A nurse should recognize that which of these occupations increases a person's risk of developing
hepatitis B? - ANSWER****Hemodialysis nurse.

Which of these assessments is the priority for a client who sustained second-degree burns of the face
and neck? - ANSWER****Respiratory status.

A nurse should place a child who is two hours post-tonsillectomy and adenoidectomy in which of these
positions? - ANSWER****Side-lying.

Which of these instructions should a nurse include in the discharge teaching for a client who has
diabetes mellitus? - ANSWER****"Apply lotion to your feet each day."

A nurse inadvertently administers an incorrect medication to a client. Which of these actions should the
nurse take first? - ANSWER****Assess the client.

An elderly client who is receiving a blood transfusion develops a rapid bounding pulse and an elevated
blood pressure. Which of these actions should a nurse take? - ANSWER****Stop the transfusion.

When caring for a client who has hepatitis B, a nurse should wear: - ANSWER****gloves when
removing the intravenous cannula.

Which of these outcome criteria is appropriate for a client who has a nursing diagnosis of ineffective
airway clearance? - ANSWER****Clear lung sounds on auscultation.
A doctor prescribes liquid oral iron medication for a 4-year-old child. Which of these questions should a
nurse ask the child's mother to determine if the medication is being administered correctly? -
ANSWER****"Are you using a straw to administer the medicine?"

Which of these assessment findings, if present in a 4-month-old infant who has severe diarrhea, should
a nurse recognize as suggestive that the infant is dehydrated? - ANSWER****Decreased urine output.

Which of these instructions should be included in the teaching plan for the parents of a 10-month-old
infant who is admitted to the hospital for failure to thrive? - ANSWER****Encourage the mother to
feed the infant slowly in a quiet environment.

When a newborn is 48 hours old, a nurse notes that the child is jaundiced. The nurse should recognize
which of these conditions as a probable cause of the newborn's jaundice? - ANSWER****Liver
immaturity.

Which of these items should a nurse removed from the food tray of a client who is on a sodium-
restricted diet? - ANSWER****Ketchup.

Which of these statements, if made by a client who had a total hip replacement, would indicate a
correct understanding of the postoperative instructions? - ANSWER****"I will use a raised toilet seat
in the bathroom."

Which of these measures should a nurse include when planning care for an 88-year-old client who is
admitted to the hospital with pneumonia? - ANSWER****Allowing the client to perform self-care as
tolerated.

A client, who is newly diagnosed with cancer says to anurse, "I suppose I need to complete all unfinished
business as soon as possible." Which of these responses is appropriate? - ANSWER****"It sounds like
you are concerned with your diagnosis."

Which of these interventions should plan for a child who is receiving chelation therapy for lead
poisoning? - ANSWER****Keeping an accurate record of intake and output.
A nurse obtains these vital signs on an adult client. Which finding should the nurse follow-up first? -
ANSWER****Respiration, 30/minute and deep.

When determining the duration of a uterine contraction, a nurse should measure the contraction from
the: - ANSWER****beginning of one contraction to the end of that contraction.

A nurse should recognize which of these signs is a probably sign of pregnancy? - ANSWER****Positive
pregnancy test.

All of these clients are on bed rest. Which one is the most at risk to develop skin breakdown? -
ANSWER****An 84-year-old client who has been NPO for four days.

A client diagnosed with type 1 diabetes mellitus has a glycosylated hemoglobin A1c of 4.2%. A nurse
should interpret this to mean that the client has: - ANSWER****been in relatively good diabetic
control.

A nurse is caring for a client with burns and in reverse isolation. Which measures should the nurse
include? - ANSWER****Wearing a gown, mask, and gloves when providing care to the client.

A physician has ordered 100 mg of Amoxicillin po for a child. The available liquid amoxicillin is 250 mg/5
mL. How many milliliters should a nurse administer? - ANSWER****2.0

A nurse charts on all assigned clients at 2:00 P.M. The nurse then remembers something that happened
at 9:00 A.M. to a client who was not charted. Which of these actions should the nurse take? -
ANSWER****Enter the scenario after the original 2:00 P.M. charting and mark it as a "late entry".

While giving a bath to a client, a nurse notices that the client's back appear reddened. Which of these
interpretations and additional assessments should the nurse make? - ANSWER****The client is
showing signs of pressure; press on the skin and observe for a return of color.

A newborn is placed under fluorescent light as part of the treatment for physiologic jaundice. During the
duration of the newborn's treatment, a nurse should: - ANSWER****cover the newborn's closed eyes
with patches.
Which of these symptoms should a nurse expect to assess in a client who develops hypoglycemia? -
ANSWER****Diaphoresis.

A client is eight hours postoperative after a transurethral resection of the prostate (TURP). Which of
these observations, if noted by a nurse, indicates a complication? - ANSWER****BP 92/60 mm Hg,
pulse rate 118/minute.

A nurse should assess a child who has diabetes mellitus (type 1) for symptoms of hyperglycemia, which
include: - ANSWER****flushed skin and thirst.

Which of these laboratory test results should a nurse monitor for a client who is receiving intravenous
heparin therapy at a rate of 1,500 units per hour for the treatment of an acute pulmonary embolism? -
ANSWER****Partial thromboplastin time.

Which of these techniques should a nurse use to assess for correct placement of a nasogastric tube prior
to administering a feeding? - ANSWER****Aspirate 10 mL contents and measure the pH.

A client has shortness of breath when lying down and usually assumes an upright or sitting position in
order to breathe more comfortably. A nurse should document this observation as: -
ANSWER****orthopnea.

Which of these instructions should a nurse give to a client when collecting a sputum specimen? -
ANSWER****"Take a deep breath, then cough and spit into this container."

A client who is receiving radiation therapy has a nursing diagnosis of imbalanced nutrition: less than
body requirements related to diminished taste perception and nausea. Which of these additional
nursing diagnoses should a nurse consider for the client? - ANSWER****Risk for deficient fluid volume.

Which of these menus, if chosen by a parent of a child who has celiac disease, would indicate to a nurse
that the parent understands the teaching about a gluten-free diet? - ANSWER****Broiled steak, baked
potato, and spinach.
Which of these statements, if made by a nurse, is non-therapeutic because it disregards a client's
feelings and concerns? - ANSWER****"Everything will be okay."

A client tells a nurse, "I am so scared about the interview tomorrow. I just know I will say the wrong
thing and not get the job." Which of these responses, if made by the nurse, will create a communication
barrier? - ANSWER****"You need to relax, and everything will be fine."

A young healthy adult, who has been exercising in hot weather, has fatigue, loss of appetite, and
lightheadedness. Which of these assessments should a nurse make? - ANSWER****Measure the
client's body temperature.

Which of these nursing measures is the priority for a child who has hemophilia and who sustains a leg
injury? - ANSWER****Administering the missing factor VIII to the child.

Which of these outcomes should a nurse focus on for a client who had a bronchoscopy two hours ago? -
ANSWER****Preventing aspiration.

A client who had a coronary artery bypass graft four days ago suddenly develops sinus tachycardia and
reports shortness of breath and dizziness. Which of these interpretations and actions should a nurse
take? - ANSWER****This may be an early sign of heart failure; notify the physician.

Which of these lunch selections, if made by a client who has congestive heart failure, should a nurse
recognize as indicative of a need for additional instructions? - ANSWER****Egg salad sandwich with
mayonnaise, pickles, and seltzer water.

Which of the statements if made by a client who is take furosemide (Lasix), supports a nursing diagnosis
of knowledge deficit? - ANSWER****"I will need to add more salt to my diet because this medication
will increase its excretion."

Which of these statements, if made by a client who has chronic obstructive pulmonary disease, indicates
improvement? - ANSWER****"I can now walk one more block than I could last month."
An 8-month-old infant is admitted to the hospital because of failure to thrive. Which of these actions
should a nurse plan? - ANSWER****Consistently assign the care of the infant to the same staff.

Which of these actions should a nurse include to enhance the effectiveness of client teaching sessions? -
ANSWER****Initially demonstrate and explain the procedure to the client.

Which of these laboratory test results is more important for a nurse to assess for a client who reports
chest pain? - ANSWER****Troponin level.

A nurse should explain to a primigravida that urine tests will be done at each prenatal visit throughout
the pregnancy to measure: - ANSWER****glucose and protein.

Which of these manifestations should a nurse expect to observe in a client who is diagnosed with
paranoid schizophrenia? - ANSWER****Suspiciousness.

Which of these measures should an emergency room nurse include when speaking with a family
experiencing the loss of an infant from Sudden Infant Death Syndrome (SIDS)? -
ANSWER****Encouraging the parents to take the opportunity to say goodbye.

Which of these assessments is the priority for a client who is admitted with recurrent depression? -
ANSWER****Presence of a suicide plan.

Which of these changes in the assessment data of a child who has congestive heart failure should a
nurse recognize as indicative of a therapeutic response to prescribed medication therapy? -
ANSWER****Increased urine output.

Which of these assignments, if delegated to unlicensed assistive personnel (UAP) by a nurse, is

appropriate? - ANSWER****The UAP is assigned to measure a client's intake and output.

A client who has a history of asthma develops an acute asthma attack. Which of these questions should
a nurse ask when assessing the etiology of this attack? - ANSWER****"Have you eaten any new foods
recently?"
Which of these foods should a nurse suggest that a client who is diagnosed with iron-deficiency anemia
choose for dinner? - ANSWER****Cooked dry beans, green leafy vegetables, and dried fruits.

A nurse in a prenatal clinic performs Leopold's maneuvers on a client who is 8-months-pregnant

primarily to: - ANSWER****determine the fetal presentation.

A child is brought to the clinical for serum lead screening because of ingestion of lead-based paint.
Which of these manifestations, if present in the child, would indicate early signs of lead toxicity? -
ANSWER****Behavior changes.

Which of these recommendations should a nurse make when teaching a client who is to start taking oral
prednisone (Deltasone)? - ANSWER****"Take this medicine in the morning with food or milk."

Which of these actions should a nurse take prior to initiating prescribed antibiotic therapy for a client
who has a urinary tract infection? - ANSWER****Obtain a urine culture specimen.

When caring for a client who is receiving oxygen therapy via nasal cannula, a nurse should instruct the
client: - ANSWER****to breathe through the nose.

Each of these clients has impaired mobility related to knee surgery. Which client should a nurse assess
first? - ANSWER****A 59-year-old who has a history of hypertension.

The mother of a 2-month-old tells a nurse that the baby is consuming six ounces of plain commercial
formula seven times a day, plus one ounce of cereal in the morning and at bedtime. Based on this
information, the nurse should conclude that the baby's diet is: - ANSWER****A 59-year-old who has a
history of hypertension.

A nurse plans to assess a client's recent memory. Which of these questions should the nurse include? -
ANSWER****"What did you have for breakfast?"

A client who has a breast tumor says to a nurse, "I am so anxious. Why did I have to get sick now?"
Which of these responses, if made by the nurse, is therapeutic? - ANSWER****"Tell me more about
your concerns."
Which of these actions, if taken by a nurse who is transferring a client from the bed to the chair, is
correct? - ANSWER****The nurse supports the client in an upright standing position for a few
moments.

A nurse should assist a pregnant client who is in the first trimester to achieve the developmental task of
this stage of pregnancy, which is: - ANSWER****accepting the fact that she is pregnant.

When interacting with a client who is paranoid, a nurse should: - ANSWER****maintain a professional
attitude towards the client.

Which of these tasks is appropriate for a nurse to delegate to a nursing assistant in an acute care unit? -
ANSWER****Measure the blood pressure of a client who was admitted with an asthma attack
yesterday.

Which of these techniques should a nurse plan to use with a client who is delusional? -
ANSWER****Focus on reality-based topics.

Which of the following manifestations should a nurse recognize as suggestive of right-sided heart
failure? - ANSWER****Jugular vein distention and pedal edema.

Which of these statements, if made by a nursing student prior to a sterile dressing change, is correct? -
ANSWER****"I understand that sterile objects that are below my waist are considered contaminated."

A nurse reviews a client's prenatal record and notes that the client's last menstrual period (LMP) was on
September 18th. Using the Naegele's rule, the nurse should calculate that the client's expected date of
delivery (EDD) will be: - ANSWER****June 25th.

Which of these instructions should a nurse give to a client who has venous insufficiency regarding the
use of elastic stockings (TEDs)? - ANSWER****"Put the TEDs on before you get up in the morning."
A nurse assesses a client who is scheduled for a total abdominal hysterectomy at 10:00 A.M. WHich of
the factors should the nurse recognize as most likely to influence the outcome of the surgery? -
ANSWER****The client takes one acetysalicylic acid (baby Aspirin) daily.

A client's urine output is 500 mL in 24 hours. Which of these actions should a nurse take? -
ANSWER****Report the findings to the physician.

A nurse should question an order for a potassium chloride intravenous infusion for which of these
clients? - ANSWER****A client who has anuria.

A 22-year-old college student has a heart rate that is 48/minute and regular during a routine physical
examination. Which of these questions should a nurse consider when analyzing this heart rate? -
ANSWER****Is this student an athlete?

Which of the following clients should a nurse recognize is most likely to develop diabetic ketoacidosis? -
ANSWER****A 23-year-old who has type 1 diabetes mellitus and is being treated for a tooth abscess.

Which of these postoperative complications in the first hour after surgery requires immediate
intervention? - ANSWER****Dehiscence of a wound.

Which of these assessments should a nurse make of a client who had a knee replacement this morning?
- ANSWER****Pain.

Which of these actions should a nurse take prior to assisting an elderly client to shave his face? -
ANSWER****Determine what medications the client takes.

Which of these factors should a nurse consider when delegating tasks to unlicensed assistive personnel
(UAP)? - ANSWER****The UAP's previous experiences on the unit.

Which of these nursing diagnoses is the priority for a young adult client who has first-degree burns of
the legs and smoke inhalation from a fire in the home? - ANSWER****Impaired gas exchange.
A child who has cystic fibrosis is receiving pancrelipase (Pancrease MT) with meals and snacks. To
determine if the desired effects of the Pancrease are achieved, a nurse should consider which of these
questions? - ANSWER****Are the child's stools of normal consistency?

When assessing a group of children, a nurse should recognize which child is at increased risk of
developing acute glomerulonephritis? - ANSWER****A 4-year-old who had a streptococcal infection a
week ago.

A client says to a nurse, "I am Alexander the Great. I am a world leader and must return to my kingdom.
I am not taking any medications. I do not want anyone to come near me. I need to protect myself if they
do." Which of these problems should the nurse focus on first? - ANSWER****Risk for violence.

When a client who has a diagnosis of depression is taking a monoamine oxidase (MAO) inhibitor, which
of these dieatry instructions should a nurse give to the client? - ANSWER****"Avoid foods that contain
tyramine, such as aged cheeses."

Which of these strategies should a nurse plan for a client who is manic and has lost 30 pounds? -
ANSWER****Nutritious finger foods.

A 15-year-old child who has type I diabetes mellitus receives an injection of regular insulin 5 units and
isophane (NPH) insulin 15 units subcutaneously at 7:00 A.M. before eating breakfast. At 10:30 A.M., the
child tells the school nurse, "I am sweating and feel weak." Which of these actions should the nurse take
first? - ANSWER****Measure the blood sugar.

A client who has a head injury is drowsy and lethargic, and has clear nasal discharge. Which of these
actions should a nurse take? - ANSWER****Test the drainage for glucose.

Which of these actions, if taken by a nursing assistant, should a nurse recognize as increasing the client's
risk of developing a nosocomial infection? - ANSWER****Placing the Foley catheter drainage bag on
the bed while transferring the client.

A nurse is preparing a client for a vaginal examination. Which of these statements should the nurse
make? - ANSWER****"Go into the bathroom and empty your bladder."
A licensed practical nurse (LPN) is assigned to care for all of these clients. Which client should the nurse
assess first? - ANSWER****A 49-year-old client who has an acute myocardial infarction related to
cocaine ingestion.

Which of these preventative measures should a nurse manager in a long-term care facility plan to
institute to decrease clients' risks for falls? - ANSWER****Monitoring clients frequently for evidence of
activity intolerance.

Which of these assessment findings, if present in a primigravida, indicates that the client is experiencing
true labor? - ANSWER****There is a progressive increase in effacement and cervical dilatation.

A client is admitted for opiate detoxification for the fifth time. Which of these statements, if made by a
staff member, indicates a biased view of the client? - ANSWER****"Addicts relapse because they don't
try hard enough."

Which of these women, each of whom is in labor, should a nurse recognize as in need of immediate
attention? - ANSWER****A woman who is in the active phase of labor and who insists she needs to
use the bedpan to have a bowel movement.

A nurse has received a report on these assigned clients. Which client should the nurse follow-up first? -
ANSWER****A client who is currently receiving cancer chemotherapy and who has a white blood cell
count of 500 mm3 today.

Which of these statements, if made by a client who is taking a diuretic, should a nurse recognize as
indicative of the need for additional instructions? - ANSWER****"I take all of my medications at
bedtime so I don't forget them."

A nurse is monitoring a client who had a cystoscopy six hours ago. The nurse should inform the physician
of which these manifestations? - ANSWER****The client's white blood cell count is 15,000 mm3.

Which of these actions should a nurse perform prior to a client's scheduled hemodialysis? -
ANSWER****Weigh the client.
A client has been in bed for the past three days. Which of these measures should a nurse include before
assisting the client out of bed? - ANSWER****Raising the head of the bed.

Which of these behaviors, if taken by a staff nurse on a psychiatric unit, indicates a correct
understanding of therapeutic techniques? - ANSWER****A nurse sets consistent limits with
manipulative clients.

A client who has insulin-dependent diabetes mellitus asks a nurse, "What should I do when I feel
nervous, sweaty, and hungry?" The nurse should give the client which of these instructions? -
ANSWER****"Eat a carbohydrate snack."

Which of these tasks should a licensed practical nurse (LPN) delegate to a nursing assistant? -
ANSWER****Ambulating a client who had a hip replacement three days ago.

A 36-week-pregnant woman awakens to find she is having profuse, red vaginal bleeding. A nurse should
prepare the woman to have an immediate sonogram to determine the: - ANSWER****location of the
placenta.

A nurse is planning to interview a client who speaks limited English. Which of these strategies should the
nurse include? - ANSWER****Observe the client for indicators of confusion or not understanding
questions.

A nurse takes the weight of a normal 2-year-old child who comes in to the pediatric clinic for a well-child
visit. If the child weighted 7 lbs, 2 oz. at birth, how much should the nurse expect the child to weight at
this visit? - ANSWER****28 lbs, 8 oz.

A nurse has been discussing the nutritional needs of children with a group of parents in a clinic. Which of
these statements, if made by the parent of a 2-year-old child, should the nurse follow up? -
ANSWER****"I give my child some popcorn as an afternoon snack."

Which of these client care situations has the greatest potential for presenting an ethical dilemma for a
nurse? - ANSWER****Participating in pregnancy termination procedures.
Which assessment information should a nurse obtain first when a pregnant woman and her husband
arrive at the Labor and Delivery Unit? - ANSWER****The frequency and intensity of labor contractions.

A client who has Parkinson's disease has been identified as being at risk for falls. Which of these actions
by a nurse is most likely to reduce the client's risk of falling? - ANSWER****Assign an assistant to
remain with the client when ambulating.

A nurse determines that the therapeutic effectiveness of magnesium sulfate (MgSO4) for client who has
preeclampsia is achieved when there is increased: - ANSWER****urinary output.

Which of these assessments is the initial priority of a client who is one-hour postoperative after an
exploratory laparotomy? - ANSWER****The adequacy of the client's respiratory function.

Which of these client reports should a nurse recognize as suggestive of hypothyroidism? -

ANSWER****"I feel cold and tired all the time."

A nurse is monitoring a client who is taking acetylsalicylic acid (Aspirin) 975 mg daily for adverse effects,
which include: - ANSWER****occult blood in the stools.

Which of these rationales explains the purpose of nasogastric tube with suction for a client who had
abdominal surgery? - ANSWER****Removal of secretions from the stomach.

A 75-year-old client who is newly admitted to a long-term care facility has all these nursing diagnoses.
Which one is the priority? - ANSWER****Risk of injury.

A 12-month-old child is playing with the father. Which of these behaviors indicates that the child is
demonstrating object permanence? - ANSWER****The child looks for a toy that the father has hidden
under the table.

A nurse should recognize that a client's selection of which of these foods demonstrates a correct
understanding of a high-fiber diet for colon cancer prevention? - ANSWER****Bran flakes.
Which of these discharge instructions should a nurse include for a client who has a ruptured tympanic
membrane that occurred during a fall? - ANSWER****"Do not allow any water to enter the ear until
healing is confirmed by direct visualization."

Which of these nursing measures is appropriate for a client who has recurrent renal calculi? -
ANSWER****Encouraging a daily intake of three liters of fluids.

When auscultating the lungs of a woman who is admitted for severe pregnancy-induced hypertension, a
nurse notes the presence of crackles and moist respirations. These assessment findings most likely
indicate which of these complications? - ANSWER****Pulmonary edema has developed.

A licensed practical nurse (LPN) is assigned to care for all of these clients. Which client should the nurse
assess first? - ANSWER****A client who is drowsy after falling out a third story window.

Which of these clients is at the highest risk of developing osteoporosis? - ANSWER****A thin, elderly
Caucasian female who lives alone.

A nurse is obtaining the health history of a client who is admitted for surgical repair of an inguinal
hernia. Which of these factors should the nurse recognize as having the greatest impact on the outcome
of the surgery? - ANSWER****The client takes several acetylsalicylic acid (Aspirin) tablets daily for
knee pain.

A nurse should recognize that a client who has chronic obstructive pulmonary disease (COPD), needs
additional instructions if the client makes which of these statements? - ANSWER****"I will turn up the
oxygen flow rate if I have difficulty breathing."

A woman is treated in the emergency room for a broken arm and multiple facial bruises caused by her
spouse. Which of these statements, if made by a nurse, is therapeutic? - ANSWER****"This type of
abuse typically recurs after a period of remorse by the abuser."