2026 ATI PN
PREDICTOR EXIT EXAM
4 FULL SET EXAMS
(NGN-STYLE QUESTIONS & CASE SCENARIOS)
Answers with detailed Rationale
What You’ll Get:
• EACH SET HAS 180 questions
• quick review
• Printable, easy-to-study PDF
Not affiliated with ATI, VATI or NCLEX. For study purposes only.
,Table of Contents
ATI PN EXIT SET 1 .............................................................................. 2
ATI PN EXIT SET 2 ............................................................................ 79
ATI PN EXIT SET 3 .......................................................................... 166
ATI PN EXIT SET 4 .......................................................................... 235
ATI PN EXIT SET 1
1. A nurse is assisting with the plan of care for a client following a transurethral
resection of the prostate. Which of the following interventions should the nurse
include in the plan of care?
A. Irrigate the bladder using strict sterile technique and maintain closed catheter
drainage system to minimize the risk of infection
B. Remove the catheter every 8 hours to prevent urinary tract infection
C. Encourage the client to void spontaneously without the catheter
D. Maintain the irrigation solution above the level of the bladder at all times
Correct Answer: A
Rationale: Following a transurethral resection of the prostate (TURP), continuous
bladder irrigation (CBI) with sterile technique is essential to prevent clot formation and
maintain catheter patency. A closed drainage system minimizes the risk of infection.
Option B is incorrect because the catheter should not be removed frequently. Option C
is incorrect because the client cannot void spontaneously with the catheter in place.
Option D is incorrect because the irrigation solution should be maintained below the
level of the bladder to prevent reflux of urine.
2. A nurse is reviewing a client's electronic medical record and finds that an
assistive personnel recorded the client's temperature as 35.3° C (95.5° F) 2 hours
earlier. Which of the following actions should the nurse take first?
,A. Document the finding and continue with routine care
B. Check the client's temperature using another method
C. Notify the provider immediately
D. Place the client in a warm blanket
Correct Answer: B
Rationale: The nurse should first verify the accuracy of the finding by rechecking the
temperature using another method. A temperature of 35.3° C indicates hypothermia, but
the nurse must validate the data before taking further action. After verification, the nurse
can implement appropriate interventions and notify the provider if confirmed.
3. A nurse is receiving change-of-shift report for four clients. Which of the
following clients should the nurse see first?
A. A client whose urinary output was 100 mL for the past 12 hours
B. A client who is requesting pain medication for a headache
C. A client who needs assistance to the bathroom
D. A client who is scheduled for discharge in 2 hours
Correct Answer: A
Rationale: A urinary output of 100 mL in 12 hours indicates oliguria (less than 30
mL/hour), which is a sign of potential renal failure, dehydration, or decreased cardiac
output. This requires immediate assessment as it can lead to life-threatening
complications. The other clients have needs that are important but not immediately life-
threatening.
4. A nurse is reinforcing teaching about weight loss with a female older adult
client who is overweight. Which of the following statements should the nurse
include in teaching?
A. Keep fat intake to no more than 30% of daily caloric intake
B. Eliminate all carbohydrates from the diet
C. Fast for 24 hours twice a week to promote weight loss
D. Consume less than 800 calories per day for rapid weight loss
Correct Answer: A
Rationale: A balanced diet for weight loss should include no more than 30% of calories
from fat, with emphasis on healthy fats. Option B is incorrect because carbohydrates
are necessary for energy. Option C is incorrect because fasting is not recommended for
,older adults and can lead to malnutrition. Option D is incorrect because very low-calorie
diets can be dangerous and are not recommended without medical supervision.
5. A nurse is collecting data from a client who has iron deficiency anemia. Which
of the following findings should the nurse expect?
A. Difficulty concentrating
B. Flushed skin
C. Bounding pulse
D. Hypertension
Correct Answer: A
Rationale: Iron deficiency anemia causes decreased oxygen-carrying capacity, leading
to fatigue, weakness, and difficulty concentrating due to reduced cerebral oxygenation.
Options B, C, and D are incorrect because anemia typically presents with pallor,
tachycardia (not bounding pulse), and hypotension (not hypertension).
6. A nurse is collecting data from an older adult client who is 48 hours
postoperative following abdominal surgery. The provider writes a prescription to
advance the client to a regular diet. For which of the following findings should the
nurse notify the provider?
A. The client has absent bowel sounds
B. The client reports mild incisional pain
C. The client has a soft, non-distended abdomen
D. The client is passing flatus
Correct Answer: A
Rationale: Absent bowel sounds indicate paralytic ileus, which is a contraindication for
advancing to a regular diet. The nurse should notify the provider before implementing
the diet order. Options B, C, and D are normal postoperative findings that do not
contraindicate diet advancement.
7. A parent brings her adolescent son to an urgent care center and states, "He is
high on something and needs help." The client is exhibiting agitation and
paranoia and reports visual hallucinations. The nurse should suspect intoxication
with which of the following substances?
,A. Methamphetamines
B. Alcohol
C. Opioids
D. Benzodiazepines
Correct Answer: A
Rationale: Methamphetamine intoxication causes agitation, paranoia, and visual
hallucinations due to its stimulant effects on the central nervous system. Alcohol
intoxication typically causes sedation and impaired coordination. Opioid intoxication
causes respiratory depression and sedation. Benzodiazepine intoxication causes
sedation and confusion, not agitation or hallucinations.
8. A nurse notices an assistive personnel taking a nap in the break room during
meal time. The AP appears drowsy while performing routine tasks. Which of the
following actions should the nurse take?
A. Report the observations about the AP to the unit's nurse manager
B. Confront the AP immediately in front of other staff
C. Ignore the behavior if the AP completes all tasks
D. Send the AP home without documentation
Correct Answer: A
Rationale: The nurse has a responsibility to report concerns about an AP's fitness for
duty to the nurse manager, as drowsiness can compromise patient safety. The nurse
should follow the chain of command and facility policy. Option B is inappropriate as it
violates professional communication standards. Options C and D fail to address the
potential safety issue appropriately.
9. A nurse is reinforcing teaching with a client who has a fluid volume deficit
about selecting foods that have a high water content. The nurse should include
that which of the following raw foods contains the highest amount of water per 1-
cup serving?
A. Cherry tomatoes
B. Raw carrots
C. Celery sticks
D. Cucumber slices
Correct Answer: A
,Rationale: Cherry tomatoes contain approximately 95% water by weight, making them
an excellent choice for hydration. While cucumbers and celery are also high in water
content, cherry tomatoes provide significant hydration along with vitamins and
antioxidants. This information helps the client make informed choices to maintain
adequate hydration.
10. The nurse is positioning a client who is scheduled for a lumbar puncture. The
nurse should assist the client into which of the following positions?
A. Lateral recumbent position with knees flexed toward the chest
B. Supine position with legs extended
C. Prone position with a pillow under the abdomen
D. Sitting position with legs dangling over the side of the bed
Correct Answer: A
Rationale: The lateral recumbent (fetal) position with knees flexed toward the chest
maximally flexes the spine, widening the intervertebral spaces for easier needle
insertion during a lumbar puncture. This position also helps prevent post-procedure
headache by reducing cerebrospinal fluid leakage.
11. A nurse is talking with a client whose son died in a motor vehicle crash 2
weeks ago. The client states, "I really thought I'd be back to my usual routines by
now, but I can't think of anything else except my son is gone." Which of the
following responses should the nurse make?
A. "Grieving for your son is hard work. It will take as much time as you need to come to
terms with your loss."
B. "You should try to get back to your normal routine to distract yourself from the pain."
C. "It's been two weeks already; you need to move on with your life."
D. "Have you considered taking antidepressants to help you feel better?"
Correct Answer: A
Rationale: This response validates the client's feelings and acknowledges that grief is a
personal process without a specific timeline. Option B minimizes the client's feelings.
Option C is dismissive and inappropriate. Option D suggests medical intervention before
assessing the normalcy of the grief response.
,12. A nurse is assisting with monitoring a client who is at 40 weeks of gestation
and is in active labor. The nurse recognizes late deceleration on the fetal monitor
tracing. Which of the following actions should the nurse take?
A. Place the client in the lateral position
B. Prepare for immediate delivery
C. Increase the rate of oxytocin infusion
D. Have the client push with each contraction
Correct Answer: A
Rationale: Late decelerations indicate uteroplacental insufficiency. Placing the client in
a lateral position improves uteroplacental perfusion by relieving pressure on the vena
cava. The nurse should also administer oxygen, discontinue oxytocin if infusing, and
notify the provider. Options B, C, and D are inappropriate responses to late
decelerations.
13. A nurse manager is providing an in-service on hand hygiene to assistive
personnel. Which of the following information should the nurse manager include
in the in-service?
A. Remove rings when washing hands with soap and water
B. Alcohol-based hand rub is ineffective against all organisms
C. Hand hygiene is only necessary after contact with body fluids
D. Artificial nails are acceptable if kept short
Correct Answer: A
Rationale: Rings and jewelry can harbor microorganisms and interfere with effective
hand washing. The CDC recommends removing rings before hand hygiene. Option B is
incorrect because alcohol-based rubs are effective against most organisms. Option C is
incorrect because hand hygiene is required before and after patient contact. Option D is
incorrect because artificial nails are associated with increased bacterial colonization.
14. A nurse is reinforcing home safety instructions with the parent of a newborn.
Which of the following statements should the nurse include in the instructions?
A. Place your baby's crib away from heat sources
B. Place pillows in the crib to keep the baby comfortable
C. Use a soft mattress and fluffy blankets for warmth
D. Position the baby on their stomach for sleep
,Correct Answer: A
Rationale: Cribs should be placed away from heat sources, windows, and cords to
prevent burns, falls, and strangulation. Options B, C, and D increase the risk of sudden
infant death syndrome (SIDS) and should be avoided. The baby should sleep on their
back on a firm mattress without pillows or loose bedding.
15. A nurse is preparing to administer a client's morning medications. Which of
the following actions should the nurse take to verify the client's identity?
A. Scan the facility identification bracelet
B. Ask the roommate to confirm the client's identity
C. Check the name on the door
D. Use the client's first name only
Correct Answer: A
Rationale: Scanning the facility identification bracelet is the most reliable method of
verifying client identity, following The Joint Commission's National Patient Safety Goals.
Options B, C, and D are not reliable methods and can lead to medication errors. The
nurse should use two identifiers, such as the bracelet and asking the client to state their
name and date of birth.
16. A nurse is caring for a client following a bronchoscopy procedure. Which of
the following actions should the nurse perform first?
A. Check for a gag reflex
B. Offer the client oral fluids
C. Assist the client to ambulate
D. Administer prescribed pain medication
Correct Answer: A
Rationale: Following bronchoscopy, the nurse must first assess the return of the gag
reflex before offering oral intake to prevent aspiration. The gag reflex may be impaired
due to local anesthesia used during the procedure. Once the gag reflex returns, the
client can begin oral intake.
17. While administering a medication to a client, a nurse notices a frayed
electrical cord connecting the client's continuous passive motion machine to the
electrical outlet. Which of the following actions should the nurse take?
,A. Remove the device from the client's room
B. Tape the frayed area with electrical tape
C. Continue using the device but monitor it closely
D. Report the issue to maintenance at the end of the shift
Correct Answer: A
Rationale: A frayed electrical cord poses a fire and electrocution hazard. The nurse
should immediately remove the device from the client's room and tag it for repair.
Options B, C, and D do not address the immediate safety risk and could result in injury
to the client or staff.
18. A nurse is caring for a client who is 4 hours postoperative following a total
thyroidectomy. Which of the following manifestations should the nurse report to
the provider as indicating possible hypocalcemia?
A. Tingling of fingers
B. Elevated blood pressure
C. Bradycardia
D. Warm, flushed skin
Correct Answer: A
Rationale: Tingling of fingers (paresthesia) is an early sign of hypocalcemia, which can
occur following thyroidectomy due to accidental removal or trauma to the parathyroid
glands. Other signs include muscle twitching, Chvostek's sign, and Trousseau's sign.
The nurse should report this immediately to prevent progression to tetany or
laryngospasm.
19. A nurse is caring for a client who has a Penrose drain. To ensure proper
placement and functioning of the drain, which of the following should the nurse
expect to observe?
A. The safety pin is present at the distal end of the drain
B. The drain is clamped when the client ambulates
C. The drain is inserted deep into the wound cavity
D. The collection bag is positioned above the wound level
Correct Answer: A
Rationale: A safety pin should be placed at the distal end of a Penrose drain to prevent
the drain from slipping back into the wound. The pin also helps secure the drain to the
, dressing. The drain should not be clamped, should not be inserted too deeply, and the
collection device should be below the wound level to promote gravity drainage.
20. A community health nurse is helping to reinforce teaching about hepatitis A
with a group of employees at a childcare center. Which of the following
characteristics should the nurse identify as an external factor that can impede
learning for the participants?
A. Poor lighting in the learning setting
B. Lack of motivation to learn
C. Previous knowledge about hepatitis
D. Cultural beliefs about disease
Correct Answer: A
Rationale: Poor lighting is an external (environmental) factor that can impede learning
by causing discomfort, eye strain, and difficulty reading materials. Options B, C, and D
are internal factors related to the learner's characteristics, not the environment.
21. A nurse is observing a newly licensed nurse who is providing tracheostomy
care for a client. The nurse identifies proper performance of the procedure when
the newly licensed nurse selects which of the following solutions to clean the
inner cannula?
A. Hydrogen peroxide
B. Sterile water
C. Normal saline
D. Acetic acid
Correct Answer: A
Rationale: Hydrogen peroxide is commonly used to clean the inner cannula of a
tracheostomy tube to remove dried secretions and crusts. After cleaning with hydrogen
peroxide, the cannula should be rinsed thoroughly with sterile saline or water before
reinsertion to prevent irritation of the tracheal mucosa.
22. A nurse is caring for a client who has right-sided heart failure. The client's
partner expresses concern that the client will die. Which of the following
responses should the nurse make?
PREDICTOR EXIT EXAM
4 FULL SET EXAMS
(NGN-STYLE QUESTIONS & CASE SCENARIOS)
Answers with detailed Rationale
What You’ll Get:
• EACH SET HAS 180 questions
• quick review
• Printable, easy-to-study PDF
Not affiliated with ATI, VATI or NCLEX. For study purposes only.
,Table of Contents
ATI PN EXIT SET 1 .............................................................................. 2
ATI PN EXIT SET 2 ............................................................................ 79
ATI PN EXIT SET 3 .......................................................................... 166
ATI PN EXIT SET 4 .......................................................................... 235
ATI PN EXIT SET 1
1. A nurse is assisting with the plan of care for a client following a transurethral
resection of the prostate. Which of the following interventions should the nurse
include in the plan of care?
A. Irrigate the bladder using strict sterile technique and maintain closed catheter
drainage system to minimize the risk of infection
B. Remove the catheter every 8 hours to prevent urinary tract infection
C. Encourage the client to void spontaneously without the catheter
D. Maintain the irrigation solution above the level of the bladder at all times
Correct Answer: A
Rationale: Following a transurethral resection of the prostate (TURP), continuous
bladder irrigation (CBI) with sterile technique is essential to prevent clot formation and
maintain catheter patency. A closed drainage system minimizes the risk of infection.
Option B is incorrect because the catheter should not be removed frequently. Option C
is incorrect because the client cannot void spontaneously with the catheter in place.
Option D is incorrect because the irrigation solution should be maintained below the
level of the bladder to prevent reflux of urine.
2. A nurse is reviewing a client's electronic medical record and finds that an
assistive personnel recorded the client's temperature as 35.3° C (95.5° F) 2 hours
earlier. Which of the following actions should the nurse take first?
,A. Document the finding and continue with routine care
B. Check the client's temperature using another method
C. Notify the provider immediately
D. Place the client in a warm blanket
Correct Answer: B
Rationale: The nurse should first verify the accuracy of the finding by rechecking the
temperature using another method. A temperature of 35.3° C indicates hypothermia, but
the nurse must validate the data before taking further action. After verification, the nurse
can implement appropriate interventions and notify the provider if confirmed.
3. A nurse is receiving change-of-shift report for four clients. Which of the
following clients should the nurse see first?
A. A client whose urinary output was 100 mL for the past 12 hours
B. A client who is requesting pain medication for a headache
C. A client who needs assistance to the bathroom
D. A client who is scheduled for discharge in 2 hours
Correct Answer: A
Rationale: A urinary output of 100 mL in 12 hours indicates oliguria (less than 30
mL/hour), which is a sign of potential renal failure, dehydration, or decreased cardiac
output. This requires immediate assessment as it can lead to life-threatening
complications. The other clients have needs that are important but not immediately life-
threatening.
4. A nurse is reinforcing teaching about weight loss with a female older adult
client who is overweight. Which of the following statements should the nurse
include in teaching?
A. Keep fat intake to no more than 30% of daily caloric intake
B. Eliminate all carbohydrates from the diet
C. Fast for 24 hours twice a week to promote weight loss
D. Consume less than 800 calories per day for rapid weight loss
Correct Answer: A
Rationale: A balanced diet for weight loss should include no more than 30% of calories
from fat, with emphasis on healthy fats. Option B is incorrect because carbohydrates
are necessary for energy. Option C is incorrect because fasting is not recommended for
,older adults and can lead to malnutrition. Option D is incorrect because very low-calorie
diets can be dangerous and are not recommended without medical supervision.
5. A nurse is collecting data from a client who has iron deficiency anemia. Which
of the following findings should the nurse expect?
A. Difficulty concentrating
B. Flushed skin
C. Bounding pulse
D. Hypertension
Correct Answer: A
Rationale: Iron deficiency anemia causes decreased oxygen-carrying capacity, leading
to fatigue, weakness, and difficulty concentrating due to reduced cerebral oxygenation.
Options B, C, and D are incorrect because anemia typically presents with pallor,
tachycardia (not bounding pulse), and hypotension (not hypertension).
6. A nurse is collecting data from an older adult client who is 48 hours
postoperative following abdominal surgery. The provider writes a prescription to
advance the client to a regular diet. For which of the following findings should the
nurse notify the provider?
A. The client has absent bowel sounds
B. The client reports mild incisional pain
C. The client has a soft, non-distended abdomen
D. The client is passing flatus
Correct Answer: A
Rationale: Absent bowel sounds indicate paralytic ileus, which is a contraindication for
advancing to a regular diet. The nurse should notify the provider before implementing
the diet order. Options B, C, and D are normal postoperative findings that do not
contraindicate diet advancement.
7. A parent brings her adolescent son to an urgent care center and states, "He is
high on something and needs help." The client is exhibiting agitation and
paranoia and reports visual hallucinations. The nurse should suspect intoxication
with which of the following substances?
,A. Methamphetamines
B. Alcohol
C. Opioids
D. Benzodiazepines
Correct Answer: A
Rationale: Methamphetamine intoxication causes agitation, paranoia, and visual
hallucinations due to its stimulant effects on the central nervous system. Alcohol
intoxication typically causes sedation and impaired coordination. Opioid intoxication
causes respiratory depression and sedation. Benzodiazepine intoxication causes
sedation and confusion, not agitation or hallucinations.
8. A nurse notices an assistive personnel taking a nap in the break room during
meal time. The AP appears drowsy while performing routine tasks. Which of the
following actions should the nurse take?
A. Report the observations about the AP to the unit's nurse manager
B. Confront the AP immediately in front of other staff
C. Ignore the behavior if the AP completes all tasks
D. Send the AP home without documentation
Correct Answer: A
Rationale: The nurse has a responsibility to report concerns about an AP's fitness for
duty to the nurse manager, as drowsiness can compromise patient safety. The nurse
should follow the chain of command and facility policy. Option B is inappropriate as it
violates professional communication standards. Options C and D fail to address the
potential safety issue appropriately.
9. A nurse is reinforcing teaching with a client who has a fluid volume deficit
about selecting foods that have a high water content. The nurse should include
that which of the following raw foods contains the highest amount of water per 1-
cup serving?
A. Cherry tomatoes
B. Raw carrots
C. Celery sticks
D. Cucumber slices
Correct Answer: A
,Rationale: Cherry tomatoes contain approximately 95% water by weight, making them
an excellent choice for hydration. While cucumbers and celery are also high in water
content, cherry tomatoes provide significant hydration along with vitamins and
antioxidants. This information helps the client make informed choices to maintain
adequate hydration.
10. The nurse is positioning a client who is scheduled for a lumbar puncture. The
nurse should assist the client into which of the following positions?
A. Lateral recumbent position with knees flexed toward the chest
B. Supine position with legs extended
C. Prone position with a pillow under the abdomen
D. Sitting position with legs dangling over the side of the bed
Correct Answer: A
Rationale: The lateral recumbent (fetal) position with knees flexed toward the chest
maximally flexes the spine, widening the intervertebral spaces for easier needle
insertion during a lumbar puncture. This position also helps prevent post-procedure
headache by reducing cerebrospinal fluid leakage.
11. A nurse is talking with a client whose son died in a motor vehicle crash 2
weeks ago. The client states, "I really thought I'd be back to my usual routines by
now, but I can't think of anything else except my son is gone." Which of the
following responses should the nurse make?
A. "Grieving for your son is hard work. It will take as much time as you need to come to
terms with your loss."
B. "You should try to get back to your normal routine to distract yourself from the pain."
C. "It's been two weeks already; you need to move on with your life."
D. "Have you considered taking antidepressants to help you feel better?"
Correct Answer: A
Rationale: This response validates the client's feelings and acknowledges that grief is a
personal process without a specific timeline. Option B minimizes the client's feelings.
Option C is dismissive and inappropriate. Option D suggests medical intervention before
assessing the normalcy of the grief response.
,12. A nurse is assisting with monitoring a client who is at 40 weeks of gestation
and is in active labor. The nurse recognizes late deceleration on the fetal monitor
tracing. Which of the following actions should the nurse take?
A. Place the client in the lateral position
B. Prepare for immediate delivery
C. Increase the rate of oxytocin infusion
D. Have the client push with each contraction
Correct Answer: A
Rationale: Late decelerations indicate uteroplacental insufficiency. Placing the client in
a lateral position improves uteroplacental perfusion by relieving pressure on the vena
cava. The nurse should also administer oxygen, discontinue oxytocin if infusing, and
notify the provider. Options B, C, and D are inappropriate responses to late
decelerations.
13. A nurse manager is providing an in-service on hand hygiene to assistive
personnel. Which of the following information should the nurse manager include
in the in-service?
A. Remove rings when washing hands with soap and water
B. Alcohol-based hand rub is ineffective against all organisms
C. Hand hygiene is only necessary after contact with body fluids
D. Artificial nails are acceptable if kept short
Correct Answer: A
Rationale: Rings and jewelry can harbor microorganisms and interfere with effective
hand washing. The CDC recommends removing rings before hand hygiene. Option B is
incorrect because alcohol-based rubs are effective against most organisms. Option C is
incorrect because hand hygiene is required before and after patient contact. Option D is
incorrect because artificial nails are associated with increased bacterial colonization.
14. A nurse is reinforcing home safety instructions with the parent of a newborn.
Which of the following statements should the nurse include in the instructions?
A. Place your baby's crib away from heat sources
B. Place pillows in the crib to keep the baby comfortable
C. Use a soft mattress and fluffy blankets for warmth
D. Position the baby on their stomach for sleep
,Correct Answer: A
Rationale: Cribs should be placed away from heat sources, windows, and cords to
prevent burns, falls, and strangulation. Options B, C, and D increase the risk of sudden
infant death syndrome (SIDS) and should be avoided. The baby should sleep on their
back on a firm mattress without pillows or loose bedding.
15. A nurse is preparing to administer a client's morning medications. Which of
the following actions should the nurse take to verify the client's identity?
A. Scan the facility identification bracelet
B. Ask the roommate to confirm the client's identity
C. Check the name on the door
D. Use the client's first name only
Correct Answer: A
Rationale: Scanning the facility identification bracelet is the most reliable method of
verifying client identity, following The Joint Commission's National Patient Safety Goals.
Options B, C, and D are not reliable methods and can lead to medication errors. The
nurse should use two identifiers, such as the bracelet and asking the client to state their
name and date of birth.
16. A nurse is caring for a client following a bronchoscopy procedure. Which of
the following actions should the nurse perform first?
A. Check for a gag reflex
B. Offer the client oral fluids
C. Assist the client to ambulate
D. Administer prescribed pain medication
Correct Answer: A
Rationale: Following bronchoscopy, the nurse must first assess the return of the gag
reflex before offering oral intake to prevent aspiration. The gag reflex may be impaired
due to local anesthesia used during the procedure. Once the gag reflex returns, the
client can begin oral intake.
17. While administering a medication to a client, a nurse notices a frayed
electrical cord connecting the client's continuous passive motion machine to the
electrical outlet. Which of the following actions should the nurse take?
,A. Remove the device from the client's room
B. Tape the frayed area with electrical tape
C. Continue using the device but monitor it closely
D. Report the issue to maintenance at the end of the shift
Correct Answer: A
Rationale: A frayed electrical cord poses a fire and electrocution hazard. The nurse
should immediately remove the device from the client's room and tag it for repair.
Options B, C, and D do not address the immediate safety risk and could result in injury
to the client or staff.
18. A nurse is caring for a client who is 4 hours postoperative following a total
thyroidectomy. Which of the following manifestations should the nurse report to
the provider as indicating possible hypocalcemia?
A. Tingling of fingers
B. Elevated blood pressure
C. Bradycardia
D. Warm, flushed skin
Correct Answer: A
Rationale: Tingling of fingers (paresthesia) is an early sign of hypocalcemia, which can
occur following thyroidectomy due to accidental removal or trauma to the parathyroid
glands. Other signs include muscle twitching, Chvostek's sign, and Trousseau's sign.
The nurse should report this immediately to prevent progression to tetany or
laryngospasm.
19. A nurse is caring for a client who has a Penrose drain. To ensure proper
placement and functioning of the drain, which of the following should the nurse
expect to observe?
A. The safety pin is present at the distal end of the drain
B. The drain is clamped when the client ambulates
C. The drain is inserted deep into the wound cavity
D. The collection bag is positioned above the wound level
Correct Answer: A
Rationale: A safety pin should be placed at the distal end of a Penrose drain to prevent
the drain from slipping back into the wound. The pin also helps secure the drain to the
, dressing. The drain should not be clamped, should not be inserted too deeply, and the
collection device should be below the wound level to promote gravity drainage.
20. A community health nurse is helping to reinforce teaching about hepatitis A
with a group of employees at a childcare center. Which of the following
characteristics should the nurse identify as an external factor that can impede
learning for the participants?
A. Poor lighting in the learning setting
B. Lack of motivation to learn
C. Previous knowledge about hepatitis
D. Cultural beliefs about disease
Correct Answer: A
Rationale: Poor lighting is an external (environmental) factor that can impede learning
by causing discomfort, eye strain, and difficulty reading materials. Options B, C, and D
are internal factors related to the learner's characteristics, not the environment.
21. A nurse is observing a newly licensed nurse who is providing tracheostomy
care for a client. The nurse identifies proper performance of the procedure when
the newly licensed nurse selects which of the following solutions to clean the
inner cannula?
A. Hydrogen peroxide
B. Sterile water
C. Normal saline
D. Acetic acid
Correct Answer: A
Rationale: Hydrogen peroxide is commonly used to clean the inner cannula of a
tracheostomy tube to remove dried secretions and crusts. After cleaning with hydrogen
peroxide, the cannula should be rinsed thoroughly with sterile saline or water before
reinsertion to prevent irritation of the tracheal mucosa.
22. A nurse is caring for a client who has right-sided heart failure. The client's
partner expresses concern that the client will die. Which of the following
responses should the nurse make?
