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    Exam Review

    1. A nurse on a pediatric unit is caring for a toddler who has poor dietary intake. Which of the following actions should the nurse take first?
      A)Encourage the family to be with the child during mealtimes
      B)Obtain the child's dietary history
      C)Offer the child nutritious snacks between meals
      D)Instruct the family to praise the child when they eat
    2. A nurse is reinforcing teaching with a client who is postpartum about the measles, mumps, andrubella (MMR) vaccine. Which of the following instructions should the nurse include in the teaching?
      A)Avoid breastfeeding for 3 days after receiving the vaccine.
      B)Your partner should also receive the MMR vaccine.
      C)If you are allergic to gluten you should not receive this vaccine.
      D)Avoid pregnancy for at least 28 days after receiving the vaccine.
    3. A nurse is preparing to perform a wet-to-dry dressing change for a client who has an infected abdominal wound. Which of the following techniques should the nurse use when performing this dressing change?
      A)Remove the tape by pulling from the center of the dressing
      B)Wear sterile gloves to remove the dressing
      C)Clean the wound from the center to the outer edges
      D)Moisten the dressing before removal
    4. A nurse is reinforcing teaching with a female client about contraception. Which of the following statements by the client indicates an understanding of the teaching?
      A)My partner will use condoms with spermicides.
      B)My partner and I will both use a condom during intercourse.
      C)I will be able to remove my contraceptive sponge immediately after intercourse.
      D)My partner and I will use petroleum jelly with latex condoms.
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    Exam Review

    1. A nurse is caring for a client who has bipolar disorder. The client yells at the nurse whenevermedication changes are prescribed by the client's provider. The nurse should identify that theclient is using which of the following defense mechanisms?
      A)Conversion
      B)Splitting
      C)Displacement
      D)Sublimation
    2. A nurse is providing care to a client who is immunocompromised. Which of the following should the nurse identify as a possible source of infection?
      A)Soiled linens are placed on the floor
      B)Waste containers are lined with single bags
      C)Dampened cloths are used for dusting the area
      D)Uncapped sharps are put in a puncture-resistant container
    3. A nurse is caring for a client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure?
      A)Administer an oral contrast solution
      B)Ensure that the client gave informed consent
      C)Inform the client the procedure will take 60 min
      D)Ensure that the client's bladder is full
    4. A nurse is assisting in the care of a client. Nurses' Notes 2000: Client presents to emergency department and states, "I have been assaulted." Client was immediately placed in a treatment room. 2015: "Client states they were out with friends this evening and had "a little too much to drink." Client states that they fell asleep at their friend's house and when they woke up all of their clothes were off and their genitals were sore. The client states, "I think someone had sex with me, but I don't remember anything." Client reports history of depression. Client is a full-time college student who lives with roommates. Client admits to drinking socially but denies illicit drug use and tobacco use. Which of the following interventions should the nurse plan to implement? Select all that apply.(SATA)
      A)Contact children and youth services
      B)Provide resources to the client for the local Alcoholics Anonymous chapter
      C)Request a consult for case management
      D)Maintain a safe and private environment for the client
      E)Administer sexually transmitted infection prophylaxis
      F)Provide resources for local support services
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    Exam Review

    1. A nurse is contributing to the plan of care for a client who has leukemia and is experiencing chronic fatigue. Which of the following interventions should the nurse plan to include?
      A)Increase protein in the diet.
      B)Increase the client's fluids to 4 L per day.
      C)Encourage the client to have continual bed rest.
      D)Encourage strength-training exercise.
    2. A nurse is collecting data from a client who has placenta previa. Which of the following findings should the nurse expect?
      A)Bright red vaginal bleeding
      B)Rigid abdomen
      C)Increased fetal movement
      D)Persistent uterine contractions
    3. A nurse is assisting with the care of a client. Laboratory Results 1100: Abdominal ultrasound: mass present in small intestine proximal to ileocecal valve. Size of mass is 6 cm x 7 cm (2.4 in x 2.8 in). Select the 4 responsibilities the nurse has in relation to the client's advance directives.(SATA)
      A)Provide the client with written information about advance directives
      B)Instruct the client that an advance directive is a legal document and must be honored by care providers
      C)Initiate a power of attorney for health care document
      D)Communicate advance directives status via the medical record and shift report
      E)Document that the provider discussed-do-not-resuscitate status with the client
      F)Inform the client that an advance directive discontinues further care
    4. A nurse is reviewing client confidentiality with other staff members. The nurse should identify that which of the following actions is an example of protecting client confidentiality?
      A)Giving change-of-shift report to a nurse outside the client's room
      B)Discussing a client's prognosis with an assistive personnel who is caring for the client
      C)Writing a client's diagnosis on the message board in the client's room
      D)Discarding worksheets containing client information in a wastebasket
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    Exam Review

    1. A nurse is assisting with postmortem care for a client who was a devout follower of Islam. Which of the following actions should the nurse take?
      A)Allow a family member of the client to stay with the client's body until burial
      B)Position the client's head toward Mecca
      C)Allow a family member to stay with the client's body for 8 hr
      D)Position the client's head northward
    2. A nurse is reinforcing teaching about breastfeeding with the mother of a full-term newbornwho is 5 days old. Which of the following statements by the mother indicates an understandingof the teaching?
      A)My baby should breastfeed 5 to 10 minutes on each breast.
      B)I should not wake my baby during the night to breastfeed.
      C)I should keep my baby on a strict feeding schedule.
      D)I should have my baby latch on to my nipple and areola during feeding.
    3. A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?(SATA)
      A)Assign the client to a negative pressure airflow room
      B)Have visitors remain at least 0.91 m (3 feet) away from the client
      C)Initiate contact precautions for the client
      D)Administer aspirin if the client develops a fever
    4. A nurse is preparing to test a client's plantar Babinski reflex. Which of the following instructions should the nurse give to prepare the client for this test?
      A)"Place your foot in my hand and I will tap the back of your heel."
      B)"Lie down and I will stroke the bottom of your foot."
      C)"Sit on the edge of the bed while I tap your knee."
      D)"Relax your arm across your chest and I will test your elbow extension."
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    Exam Review

    1. A nurse is assisting with the discharge of an older adult client who has early onset dementiaand lives with their adult child who works full time Which of the following resources should thenurse recommend to the family to assist with the client's care?
      A)Hospice care
      B)Long-term care facility
      C)Adult day care facility
      D)Community senior center
    2. A nurse at an outpatient clinic receives a call from a client who reports experiencing syncope after starting a new prescription for enalapril. Which of the following instructions should the nurse give the client?
      A)Decrease daily fluid intake.
      B)Withhold the medication if pulse rate is less than 60/min
      C)Rise slowly from a sitting position to a standing position
      D)Increase dietary potassium
    3. A nurse is assisting a client who has irritable bowel syndrome with meal selections. Which of the following foods should the nurse remind the client to include in her diet?
      A)Yogurt
      B)Honey
      C)Watermelon
      D)Ice cream
    4. A nurse is reinforcing teaching with the guardians of a 6-year-old child who has cystic fibrosis. Which of the following information should the nurse include in the teaching?
      A)Do not include your child when making decisions about treatment.
      B)Ensure that your child does not receive the influenza vaccine annually.
      C)Have your child wear a medical identification wristband.
      D)Provide homeschooling for your child.
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    Exam Review

    1. A nurse is assisting a client who requests to take a tub bath. Which of the following actions should the nurse take?
      A)Check on the client every 10 min during the bath
      B)Add bath oil to the water after the client gets into the tub
      C)Drain the tub water before the client gets out
      D)Allow the client to remain in the bath for 30 min
    2. A nurse is reinforcing discharge teaching with a client who has stable angina pectoris. Which of the following statements by the client indicates an understanding of what to do when chest pain occurs?
      A)"I will call the provider after taking one dose of nitroglycerin."
      B)"I will hold my breath and bear down."
      C)"I will stop what I am doing and lie down."
      D)"I will take two 325 milligram aspirin tablets at the same time.”
    3. Oxygen at 1 to 2 L/min. The nurse should ensure that the client has which of the following supplies upon discharge?
      A)Nasal cannula
      B)Petroleum jelly
      C)Oxygen mask
      D)Reservoir bag
    4. A charge nurse in a long-term care facility notices the smell of alcohol on a nurse's breath. Which of the following actions should the nurse take first?
      A)Assign clients to the remaining staff.
      B)Document objective findings about the situation.
      C)Remove the nurse from the client care area.
      D)Call the supervisor to ask for another nurse.
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