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ANSWER Clean sutures along the incision site.
of the following actions should the nurse take next? - CORRECT
retrieving the suture remover kit and applying sterile gloves
changing the client's dressing
ANSWER Administer pain medication 45 minutes before
Ask the client's family members if they would like to view the
Wash the client's body
A nurse in a long-term care facility is caring for a client who dies
during the nurse's shift. Identify the sequence in which the nurse
should perform the following steps. - CORRECT ANSWER
Obtain the pronouncement of death from the provider
Remove tubes and indwelling lines
2025 ANTI FUNDAMENTALS PROCTORED
TEST LATEST REAL
QUESTIONS AND CORRECT ANSWERS GRADE A
A nurse has just inserted an NG tube for a client. Which of the
following assessment findings should the nurse expect to confirm
correct tube placement? - CORRECT ANSWER An x-ray shows
the end of the tube above the pylorus
A nurse has an order to remove sutures from a client. After
, which
body
▪ Place a name tag on the body
A nurse is caring for a client who is postoperative. When the
nurse prepares to change her dressing she says, "Every time you
change my bandage, it hurts so much" which of the following
interventions is the nurse's priority action? - CORRECT
the nurse initiate? - CORRECT ANSWER Droplet
Which of the following types of transmission precautions should
A nurse is caring for a client who has a pharyngeal diphtheria.
A nurse is evaluating an client who is taking chlorpromazine.
Which of the following findings indicates that the medication is
effective? - CORRECT ANSWER Decreased Hallucinations
should the nurse delegate to an assistive personnel? -
CORRECT
ANSWER Arrange the lunch tray for a client with a hip fracture
A nurse is teaching a client whose left leg is in a cast about using
crutches. Which of the following statements should the nurse
identify as an indication that the client understands the teaching?
- CORRECT ANSWER "When descending stair, I will first shift
my weight to my right leg."
A nurse enters a client's room ad finds her on the floor. The
client's roommate reports that the client fell getting out of bed.
Which of the following statements should the nurse document? -
CORRECT ANSWER "Client was found lying on floor."
A nurse is checking blood pressures at a community health
screening. Which of the following clients is at high risk for primary
hypertension? - CORRECT ANSWER A client who has an
elevated LDL
A nurse is caring for four clients. Which of the following tasks
A nurse is caring for a client who requires an alternative
communication method. Which of the following is an appropriate
intervention by the nurse? - CORRECT ANSWER Suggest that
every year."
CORRECT ANSWER "You should have a fecal occult blood test
A nurse is caring for a client who requires bed rest and has a
prescription for antiembolic stockings. Which of the following
A nurse is administering IV fluid to an older adult client. The nurse
should perform which priority assessment to monitor for adverse
effects? - CORRECT ANSWER Auscultate Lung Sounds
A nurse is responding to a call light and finds a client lying on the
bathroom floor. Which of the following actions should the nurse
take first? - CORRECT ANSWER Check the client for injuries
violation of HIPAA guidelines? - CORRECT ANSWER A nurse
asks a nurse from another unit to assist with her documentation.
the stockings at least once per shift.
A nurse is teaching an older client who is at risk for osteoporosis
about beginning a program of regular physical activity. Which of
the following types of activity should the nurse recommend? -
CORRECT ANSWER Walking Briskly
A nurse is assessing an adult client who has been immobile for
the past 3 weeks. The nurse should identify that which of the
following findings requires further intervention? - CORRECT
ANSWER Erythema on pressure points
A nurse in a clinic is caring for a middle adult client who states,
"The doctor says that, since I am at an average risk for colon
cancer, I should have routine screening. What does that involve?"
Which of the following responses should the nurse make? -
actions should the nurse take? - CORRECT ANSWER Remove
Use antimicrobial sanitizer for hand hygiene.
into the esophagus.
A nurse is caring for a client who has a prescription for 5 units of
regular insulin and 10 units of NPH insulin to mix together and
administer subcutaneously. Determine the correct order of steps
for this procedure. - CORRECT ANSWER Air into NPH
Air into Regular
Draw up Regular
Draw up NPH
licensed nurses. Which of the following interventions should the
A nurse is reviewing practice guidelines with a group of newly
A nurse manager is preparing to review medication
documentation with a group of newly licensed nurses. Which of
the following statements should the nurse manager plan to
include in the teaching? - CORRECT ANSWER "Use the
complete name of the medication magnesium sulfate."
A nurse is caring for a client who has tuberculosis. Which of the
following actions should the nurse take? - CORRECT ANSWER
Place the client in a room with negative-pressure airflow.
Wear gloves when assisting the client with oral care.
nurse include that is within the RN scope of practice? -
CORRECT ANSWER Initiate an enteral feeding through a
gastrostomy tube.
A nurse is caring for a client who requires an NG tube for stomach
decompression. Which of the following actions should the nurse
take when inserting the NG tube? - CORRECT ANSWER Have
the client take sips of water to promote insertion of the NG tube
A nurse is preparing a change-of-shift report. Which of the
A nurse is caring for a client who is having difficulty breathing.
The client is lying in bed with a nasal cannula delivering oxygen.
Which of the following interventions should the nurse take first? -
CORRECT ANSWER Assist the client to an upright position.
CORRECT ANSWER Cleanse the wound from the center
outward.
A nurse is providing care to four clients. Which of the following
situations requires the nurse the complete an incident report? -
CORRECT ANSWER A client who has an IV infusion pump
receives an additional 250 mL of IV fluid.
A nurse is caring for a client receiving fluid through a peripheral IV
catheter. Which of the following findings at the IV site should the
nurse identify as infiltration? - CORRECT ANSWER Skin
Blanching
following tools or documents should the nurse use to
communicate continuity of care? - CORRECT ANSWER
Situation, Background, Assessment, and Recommendation
(SBAR)
A nurse is admitting a client who has an abdominal wound with a
large amount of purulent drainage. Which of the following types of
transmission precautions should the nurse initiate? - CORRECT
ANSWER Contact Precautions
A nurse is reviewing a client's fluid and electrolyte status. Which
of the following findings should the nurse report to the provider? -
CORRECT ANSWER Potassium 5.4 meq/L
medication to a client. The nurse draws out 1 mL of the
ANSWER Select a suction catheter that is half the size of the
lumen.
the following actions should the nurse plan to take? - CORRECT
secretions from a client who has a new tracheostomy. Which of
A nurse is reviewing protocol in preparation for suctioning
understands how to manage this therapy at home? - CORRECT
ANSWER "I'll check the wires and cables on my TV to make sure
they are in good working order."
should the nurse identify as an indication that the client
oxygen therapy at home. Which of the following statements
A nurse is giving discharge instructions to a client who will require
oid A nurse is preparing to administer an injection of an opi
A nurse is caring for a client who is refusing a blood transfusion
for religious reasons. The client's partner wants the client to have
the blood transfusion. Which of the following actions should the
nurse take? - CORRECT ANSWER Withhold the blood
transfusion.
A nurse in a long-term care facility is planning to perform hygiene
care for a new resident. Which of the following assessment
questions is the nurse's priority before beginning this procedure? -
CORRECT ANSWER "Are you able to help with your hygiene
care?"
medication from a 2 mL vial. Which of the following actions should
who is sitting in a chair. To prevent self-injury, which of the
following actions should the nurse take when lifting this object? -
CORRECT ANSWER Stand close to the cabinet when lifting it.
A nurse is lifting a bedside cabinet to move it closer to a client
adult client. Which of the following actions should the nurse plan
A nurse is planning to insert a peripheral IV catheter for an older
treatment a client is willing to accept in the event of a serious
illness."
A nurse is completing an admission assessment for a client who
reports vomiting and diarrhea for the past 3 days. Which of the
following assessment findings should the nurse expect? -
CORRECT ANSWER Rapid Heart Rate
A nurse is caring for a client who has an NG tube and is receiving
intermittent feedings through an open system. Which of the
following actions should the nurse take first? - CORRECT
ANSWER Tell the client to keep the head of the bed elevated at
least 30 degrees.
A nurse is administering an otic medication to an older adult
client. Which of the following actions should the nurse take to
ensure that the medication reaches the inner ear? - CORRECT
ANSWER Pressing gently on the tragus of the client's ear.
A nurse is using an open irrigation technique to irrigate a client's
indwelling urinary catheter. Which of the following actions should
the nurse take? - CORRECT ANSWER Subtract the amount of
irrigant used from the client's urine output.
to take? - CORRECT ANSWER Place the client's arm in a
A nurse is assisting a client who is post operative with the use of
an incentive spirometer. Into which of the following positions
should the nurse place the client? - CORRECT ANSWER
SemiFowler's
dependent position.
catheter.
CORRECT ANSWER ▪A 16 year old client who is married.
Which of the following signatures may the nurse legally witness? -
A nurse is administering 1L of 0.9% sodium chloride to a client
who is postoperative and has fluid-volume deficit. Which of the
following changes should the nurse identify as an indication that
the treatment was successful? - CORRECT ANSWER Decrease
in Heart Rate
A nurse working in the ED is witnessing the signing of informed
consent forms for the treatment of multiple clients during her shift.
A nurse is preparing to transfer a client who can bear weight
on
▪ A 27 year old who has schizophrenia.
▪ An adoptive parent who brings in his 8 year old son.
▪ A 17 year old mother who brings in her toddler.
A nurse is caring for a client who has a respiratory infection.
Which of the following techniques should the nurse use when
performing nasotracheal suctioning for the client? - CORRECT
ANSWER Apply intermittent suction when withdrawing the
one leg from the bed to a chair. After securing a safe
A nurse is caring for a group of clients. Which of the following
actions should the nurse take to prevent the spread of infection? -
hypotension
next? - CORRECT ANSWER Assess the client for
orthostatic
environment, which of the following actions should the nurse
take
about them."
A nurse is caring for a client who has a heart murmur. The nurse
is preparing to auscultate the pulmonary valve. Over which of the
following locations should the nurse place the bell of the
stethoscope? - CORRECT ANSWER Second intercostal space
at the left sternal boarder
approaching death. The client's respirations are noisy from
A nurse is caring for a client who has a terminal illness and is
nurse ask when assessing the quality of the client's pain? -
physical therapy. Which of the following questions should the
A nurse is assessing a client who reports increased pain following
CORRECT ANSWER Evaluate Electrolytes
secretions in her airway and she is short of breath. Which of the
following actions should the nurse take? - CORRECT ANSWER
Elevate the head of the client's bed
A nurse is caring for a client who has a terminal diagnosis and
whose health is declining. The client requests information about
advance directives. Which of the following responses should the
nurse make? - CORRECT ANSWER "We can talk about
advance directives, and I can also give you some brochures
CORRECT ANSWER "Is your pain sharp or dull?"
A nurse is giving a change-of-shift report about a client he
admitted earlier that day who has pneumonia. Which of the
following pieces of information is the priority for the nurse to
provide? - CORRECT ANSWER Breath Sounds
of the following actions should the nurse plan to take first? -
CORRECT ANSWER Notify the nursing manager
which of the following actions should the nurse take next? -
therapy via a peripheral IV catheter. After which of the following
A nurse is caring for a client who is receiving parenteral fluid
A nurse is initiating a protective environment for a client who has
had an allogeneic stem cell transplant. Which of the following
precautions should the nurse plan for this client? - CORRECT
A nurse is reviewing the medical records of a client who has a
pressure ulcer. Which of the following findings should the nurse
expect? - CORRECT ANSWER Albumin Level of 3g/dL
A nurse is caring for a client who is postoperative and has signs
of hemorrhagic shock. When the nurse notifies the surgeon, he
directs her to continue to measure the client's vitals every 15
minute and call him back in 1 hour. From a legal perspective,
observations should the nurse remove the IV catheter? -
CORRECT ANSWER Swelling and coolness are observed at the
IV site
A nurse on a medical-surgical unit is caring for a client who has a
new prescription for wrist restraints. Which of the following actions
should the nurse take? - CORRECT ANSWER Pad the client's
wrist before applying the restraints.
A nurse in a provider's office is obtaining the health and
medication history of a client who has a respiratory infection. The
client tells the nurse that she is not aware of any allergies, but that
she did develop a rash the last time she was taking an antibiotic.
Which of the following information should the nurse give to the
client? - CORRECT ANSWER "We need to document the exact
medication you were taking because you might be allergic to it."
lunch
Use a communication board to ask what the client wants for
A charge nurse is observing a newly licensed nurse prepare a
sterile field. Which of the following actions should the charge
nurse identify as contaminating the sterile field? - CORRECT
ANSWER The nurse opens the sterile field on a wet surface
lesion on his anterior thigh and expresses concern about skin
A nurse is performing a skin assessment of a client who has a
A nurse is caring for a client who has an aggressive form of
prostate cancer. The provider briefly discusses treatment options
and leaves the client's room. When the nurse asks if the client
would like to discuss any concerns, the client declines. Which of
the following statements should the nurse make? - CORRECT
ANSWER "I am available to talk if you should change your mind."
A nurse is caring for a client who has a sodium level of 125mEq/L.
resulting in aphasia and dysphagia. Which of the following tasks
should the nurse assign to an assistive personnel (AP)? -
CORRECT ANSWER ▪Assist the client with a partial bed bath
▪ Measure the client's BP after the nurse administers an
antihypertensive medication
cancer. Which of the following findings should the nurse report to
the provider as a possible indication of a skin malignancy? -
CORRECT ANSWER An uneven shape
A nurse is admitting a client who has been having frequent
tonicclonic seizures. Which of the following actions should the
nurse add to the client's plan of care? - CORRECT ANSWER
Wrap blankets around all four side rails
A nurse is planning care for a client who has had a stroke,
hours.
washed out the feeding bag with warm water once every 24
CORRECT ANSWER Abdominal Cramping
A nurse is preparing to administer 750 mL of 0.9% sodium
chloride IV to infuse over 7 hr. The nurse should set the infusion
pump to deliver how many mL/hr? (Round the answer to the
nearest whole number. Use a leading zero if it applies. Do not use
a trailing zero.) - CORRECT ANSWER 107 mL/hr
A nurse is providing home care for a client who is receiving tube
feedings and medication through a gastrostomy tube. The family
nurse intervene? - CORRECT ANSWER The family member
Which of the following findings should the nurse expect? -
member providing the feedings reports that the client has begun
to have diarrhea. For which of the following practices should the
