Vati Green Ligth Comprehensive form A,B,C
1. A nurse is admitting a client who has antisocial personality disorder.Which
of the following client behaviors should the nurse identify as consistent with this disorder?
a) Compulsive attention to details
b) Avoids interacting with others
c) Uses others for personal gain
d) Socially awkward in group situations: C. Uses others for personal gain
2. A nurse is interpreting the cardiac rhythm strip of a client who was admitted with syncope.Which of the following
images indicates that the client has atrial fibrillation?:
3. A client who has a diagnosis of complete placenta previa is admitted to the labor and delivery suite at 36 weeks
gestation with contractions 5 min in frequency and 1 min in duration.Which of the following actions should the
nurse take?
a) Rupture the amniotic sac
b) Medicate the client for pain
c) Prepare the client for a cesarean section
d) Perform a vaginal exam: C. Prepare the client for a cesarean section
4. A charge nurse on a pediatric unit is making assignments for a float nurse from the medical unit. Which of the
following clients is appropriate to assign to the float nurse?
a) A 10-year-old client who has pneumonia and is receiving respiratory treat- ments
b) A 4-year-old client who has a Wilms tumor and is receiving chemotherapy
c) An 8-month-old client who is scheduled for a surgical repair of a ventricular septal defect tomorrow
d) A 14-year-old client who is scheduled for discharge today following place- ment of a Harrington rod: A. A 10-
year-old client who has pneumonia and is receiving respiratory treatments
5. A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket. After moving the
client to safety, which of the following is the priority action?
a) Notify the facility operator.
b) Close the fire doors on the unit.
,c) Turn off oxygen sources.
d) Put out the fire with the appropriate extinguisher.: A. Notify the facility opera- tor.
6. A nurse is assessing an infant who has water intoxication.Which of the following findings should the nurse
expect?
a) Generalized edema
a) Elevated urine specific gravity
b) Thready pulse
c) Increased hematocrit: A. Generalized edema
7. A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse.Which of the following
statements indicates the newly licensed nurse understands the purpose of the technique?
a) This technique prevents injury to the sciatic nerve
b) This technique decreases the risk of subcutaneous infiltration
c) This technique allows a larger amount of medication to be injected
d) This technique increases the absorption rate of the drug: This technique decreases the risk of subcutaneous
infiltration
8. A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following
interventions should the nurse include in the plan?
a) Encourage the client to gain 2.3 kg per week
b) Weigh the client once per week throughout hospitalization
c) Monitor the client for 1 hr after meals
d) Allow the client to choose mealtimes: C. Monitor the client for 1 hr after meals
9. A nurse is planning care for a child who has increased intracranial pressure with a decrease in level of
consciousness.Which of the following interven- tions should the nurse include in the plan of care?
a) Perform active range-of-motion exercises
b) Maintain the head at a midline position
c) Suction the airway frequently
d) Perform neurological checks every 4 hrs: B. Maintain the head at a midline position
10. 10. A nurse is assessing a client who has delirium due to a febrile illness. Which of the following findings
should the nurse expect?
,a) Hallucinations
b) Agnosia
c) Bradycardia
d) Aphasia: A. Hallucinations
11. A nurse is assessing a client who is receiving enteral feedings via a gas- trostomy tube. The nurse should
identify that which of the following findings indicates fluid overload?
a) Diminished bowel sounds
b) Bradycardia
c) Hypotension
d) Bounding pulses: D.Bounding pulses
12. A nurse is caring for a client following an open colectomy.Which of the
following findings places the client at risk for delayed wound healing?
a) INR 1.1
b) Hyperemesis
c) HbA1c 5.6%
d) Uncontrolled pain: B. Hyperemesis
13. A home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The nurse should
evaluate which of the following laboratory tests to determine effective long-term management of blood glucose
levels?
a) 3-hr oral glucose tolerance test
b) HbA1c
c) Fasting blood glucose test
d) Urinalysis for ketones: B. HbA1c
14. A nurse is caring for a client who has neutropenia due to HIV.Which of the following precautions should the
nurse take while caring for this client?
a) Wear an N95 respirator
b) Insert an indwelling urinary catheter to monitor urinary output
c) Monitor the client's vital signs every 8 hr
d) Use a dedicated stethoscope: D.Use a dedicated stethoscope
15. A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions
, should the nurse take?
a) Encourage the client to ambulate in the hallway 1 hr before bedtime
b) Tell the client to avoid drinking fluids 1 hr before bedtime
c) Schedule routine care tasks during hours when the client is awake
d) Advise the client to leave the television in the room on when trying to fall asleep: C. Schedule routine care
tasks during hours when the client is awake
16. A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy.Which of the
following interventions should the nurse include?
a) Clothe the newborn in light cotton
b) Check the newborn's temperature every 8 hrs. (every 4)
c) Administer 120 mL of water between feedings
d) Place the newborn 45 cm from the light source: D. Place the newborn 45 cm from the light source
17. A nurse is planning care for a client who has schizophrenia and is having difficulty expressing their feelings.
Which of the following referrals should the nurse make?
a) Art therapist
b) Speech-language pathologist
c) Social worker
d) Recreational therapist: A. Art therapist
18. A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the
following findings indicates the client is experi- encing an adverse effect of the medication?
a) Decreased reflexes
b) Weight gain of 1.4 kg
c) Increased urinary output
d) Jugular vein distention: A. Decreased reflexes
19. At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports.
Which of the following client reports should the nurse assess first?
a) Constipation
b) Indigestion
c) Swollen ankles
d) Urinary frequency: B. Indigestion
1. A nurse is admitting a client who has antisocial personality disorder.Which
of the following client behaviors should the nurse identify as consistent with this disorder?
a) Compulsive attention to details
b) Avoids interacting with others
c) Uses others for personal gain
d) Socially awkward in group situations: C. Uses others for personal gain
2. A nurse is interpreting the cardiac rhythm strip of a client who was admitted with syncope.Which of the following
images indicates that the client has atrial fibrillation?:
3. A client who has a diagnosis of complete placenta previa is admitted to the labor and delivery suite at 36 weeks
gestation with contractions 5 min in frequency and 1 min in duration.Which of the following actions should the
nurse take?
a) Rupture the amniotic sac
b) Medicate the client for pain
c) Prepare the client for a cesarean section
d) Perform a vaginal exam: C. Prepare the client for a cesarean section
4. A charge nurse on a pediatric unit is making assignments for a float nurse from the medical unit. Which of the
following clients is appropriate to assign to the float nurse?
a) A 10-year-old client who has pneumonia and is receiving respiratory treat- ments
b) A 4-year-old client who has a Wilms tumor and is receiving chemotherapy
c) An 8-month-old client who is scheduled for a surgical repair of a ventricular septal defect tomorrow
d) A 14-year-old client who is scheduled for discharge today following place- ment of a Harrington rod: A. A 10-
year-old client who has pneumonia and is receiving respiratory treatments
5. A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket. After moving the
client to safety, which of the following is the priority action?
a) Notify the facility operator.
b) Close the fire doors on the unit.
,c) Turn off oxygen sources.
d) Put out the fire with the appropriate extinguisher.: A. Notify the facility opera- tor.
6. A nurse is assessing an infant who has water intoxication.Which of the following findings should the nurse
expect?
a) Generalized edema
a) Elevated urine specific gravity
b) Thready pulse
c) Increased hematocrit: A. Generalized edema
7. A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse.Which of the following
statements indicates the newly licensed nurse understands the purpose of the technique?
a) This technique prevents injury to the sciatic nerve
b) This technique decreases the risk of subcutaneous infiltration
c) This technique allows a larger amount of medication to be injected
d) This technique increases the absorption rate of the drug: This technique decreases the risk of subcutaneous
infiltration
8. A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following
interventions should the nurse include in the plan?
a) Encourage the client to gain 2.3 kg per week
b) Weigh the client once per week throughout hospitalization
c) Monitor the client for 1 hr after meals
d) Allow the client to choose mealtimes: C. Monitor the client for 1 hr after meals
9. A nurse is planning care for a child who has increased intracranial pressure with a decrease in level of
consciousness.Which of the following interven- tions should the nurse include in the plan of care?
a) Perform active range-of-motion exercises
b) Maintain the head at a midline position
c) Suction the airway frequently
d) Perform neurological checks every 4 hrs: B. Maintain the head at a midline position
10. 10. A nurse is assessing a client who has delirium due to a febrile illness. Which of the following findings
should the nurse expect?
,a) Hallucinations
b) Agnosia
c) Bradycardia
d) Aphasia: A. Hallucinations
11. A nurse is assessing a client who is receiving enteral feedings via a gas- trostomy tube. The nurse should
identify that which of the following findings indicates fluid overload?
a) Diminished bowel sounds
b) Bradycardia
c) Hypotension
d) Bounding pulses: D.Bounding pulses
12. A nurse is caring for a client following an open colectomy.Which of the
following findings places the client at risk for delayed wound healing?
a) INR 1.1
b) Hyperemesis
c) HbA1c 5.6%
d) Uncontrolled pain: B. Hyperemesis
13. A home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The nurse should
evaluate which of the following laboratory tests to determine effective long-term management of blood glucose
levels?
a) 3-hr oral glucose tolerance test
b) HbA1c
c) Fasting blood glucose test
d) Urinalysis for ketones: B. HbA1c
14. A nurse is caring for a client who has neutropenia due to HIV.Which of the following precautions should the
nurse take while caring for this client?
a) Wear an N95 respirator
b) Insert an indwelling urinary catheter to monitor urinary output
c) Monitor the client's vital signs every 8 hr
d) Use a dedicated stethoscope: D.Use a dedicated stethoscope
15. A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions
, should the nurse take?
a) Encourage the client to ambulate in the hallway 1 hr before bedtime
b) Tell the client to avoid drinking fluids 1 hr before bedtime
c) Schedule routine care tasks during hours when the client is awake
d) Advise the client to leave the television in the room on when trying to fall asleep: C. Schedule routine care
tasks during hours when the client is awake
16. A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy.Which of the
following interventions should the nurse include?
a) Clothe the newborn in light cotton
b) Check the newborn's temperature every 8 hrs. (every 4)
c) Administer 120 mL of water between feedings
d) Place the newborn 45 cm from the light source: D. Place the newborn 45 cm from the light source
17. A nurse is planning care for a client who has schizophrenia and is having difficulty expressing their feelings.
Which of the following referrals should the nurse make?
a) Art therapist
b) Speech-language pathologist
c) Social worker
d) Recreational therapist: A. Art therapist
18. A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the
following findings indicates the client is experi- encing an adverse effect of the medication?
a) Decreased reflexes
b) Weight gain of 1.4 kg
c) Increased urinary output
d) Jugular vein distention: A. Decreased reflexes
19. At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports.
Which of the following client reports should the nurse assess first?
a) Constipation
b) Indigestion
c) Swollen ankles
d) Urinary frequency: B. Indigestion
