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    Exam Review

    1. Which of the following interventions is important for promoting safety in older adult clients?
      A)Limiting communication with healthcare providers
      B)Avoiding home safety assessments
      C)Encouraging regular physical activity
      D)Encouraging isolation and limited social interactions
    2. A nurse is preparing to reposition a client. Which of the following actions should the nurse take first?
      A)Raise the height of the client's bed.
      B)Tighten their abdominal muscles.
      C)Place their feet in line with their shoulders.
      D)Pivot their feet in the direction of the move.
    3. A nurse is preparing to obtain an electronic blood pressure measurement on a client. Which of the following actions should the nurse plan to take?
      A)Elevate the client's arm above the level of the heart.
      B)Place the blood pressure cuff 5 cm (2 in) above the clients antecubital space.
      C)Align the artery indicator on the blood pressure cuff with the client's brachial artery.
      D)Select a cuff that covers 50% of the client's upper arm.
    4. A nurse is obtaining an oxygen saturation on a client. Which of the following actions should the nurse take?
      A)Wait 10 sec after placing the probe before obtaining the oxygen saturation reading
      B)Choose a finger with a capillary refill less than 2 sec.
      C)Place the sensor probe on the same extremity as an electronic blood pressure cuff.
      D)Relocate the sensor every 8 hrs.
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    Exam Review

    1. A nurse is assisting with the care of a client who is placed on supplemental oxygen for hypoxia. The nurse should identify that which of the following findings indicate the intervention was effective?
      A)Restlessness
      B)Respiratory rate 28/min
      C)Pink mucous membranes
      D)Heart rate 110/min
    2. A nurse is performing passive range of motion on a client who had a stroke. The nurse should identify that passive range of motion is performed to increase which of the following?
      A)Joint flexibility
      B)Bone density
      C)Muscle strength
      D)Muscle mass
    3. A nurse is assisting with the plan of care for a client who is immobile and is experiencing urinary retention. The nurse should plan to monitor the client for which of the following?
      A)Bladder outlet obstruction
      B)Urinary tract infection
      C)Protein in the urine
      D)Neurogenic bladder
    4. A nurse is assisting with the care of a client who is on bedrest and is experiencing constipation. Which of the following interventions should the nurse implement?
      A)Request a prescription for mineral oil for the client.
      B)Increase the client's fluid intake.
      C)Place the client on a low-fiber diet.
      D)Encourage the client to drink cold fluids.
    Page 2 of 11

    Exam Review

    1. A nurse is reinforcing teaching with a newly licensed nurse about health care-associated infections (HAIs). Which of the following examples should the nurse include as examples of HAIS? (Select All that Apply.)(SATA)
      A)A client who has pneumonia after being on a ventilator
      B)A client who has a bladder infection and has an indwelling urinary catheter
      C)A client who has an infection at their central-line insertion site
      D)A client who has a surgical site infection
      E)A client who has influenza acquired from a coworker
    2. A nurse sees smoke coming from the central supply room. Which of the following actions should the nurse take first?
      A)Stay close to the ground.
      B)Close all the doors.
      C)Wrap clients in blankets.
      D)Walk to a safe area.
    3. A nurse is caring for a client who has an oxygen saturation of 88%. Which of the following actions should the nurse take?
      A)Ask the client to cough every 4 hr.
      B)Decrease the head of the client's bed.
      C)Request a prescription for an opioid analgesic
      D)Encourage the client to take deep breaths.
    4. A nurse is preparing to administer amoxicillin tablets to a pediatric patient. The prescribed dose is 250 mg of amoxicillin. Each tablet contains 125 mg of amoxicillin. How many tablets should the nurse administer?
      A)4 tablets
      B)1 tablet
      C)2 tablets
      D)3 tablets
    Page 3 of 11

    Exam Review

    1. A nurse is reviewing the documentation of a client's blood pressure by a newly licensed nurse. The documentation states, "Blood pressure 102/58 mm Hg client sitting up in a chair." Which of the following information should the nurse clarify?
      A)Unit of measurement
      B)Position of the client
      C)Systolic blood pressure
      D)Location of blood pressure cuff
    2. A nurse is reinforcing teaching with a newly licensed nurse about documenting vital signs. Which of the following documentation made by the newly licensed nurse indicates an understanding of the teaching?
      A)Radial pulse regular 68/min
      B)BP 148/72 mm Hg
      C)Temp 36° C (96.8° F)
      D)Sp02 95%
    3. A nurse is collecting data on a client to check for orthostatic hypotension. Which of the following actions should the nurse take first?
      A)Assist the client into a standing position.
      B)Place the client in a sitting position.
      C)Check the blood pressure with the client in a supine position.
      D)Determine the client's blood pressure 1 min after each position change.
    4. A nurse is caring for a client who has hypoglycemia. The nurse should monitor the client for which of the following adverse effects of hypoglycemia?
      A)Increased urination
      B)Decreased blood pressure
      C)Fever
      D)Metabolic acidosis
    Page 4 of 11

    Exam Review

    1. Which of the following is a suitable client identifier for nurses to use when identifying a client?
      A)Client's date of birth
      B)Client's favorite food
      C)Client's room number
      D)Client's medical diagnosis
    2. A charge nurse is reinforcing teaching with a group of staff members about hand hygiene. Which of the following information should the nurse include in the teaching? (Select All that Apply.)(SATA)
      A)Clients should be instructed about hand hygiene
      B)One out of 40 clients obtain a healthcare-associated infection HAL
      C)Compliance of hand washing among staff members is less than 50%
      D)Hand hygiene is the most important step to prevent spreading of infection.
      E)Alcohol-based hand gel is an acceptable method of hand hygiene
    3. A nurse is reviewing a client's medical record. Which of the following findings should the nurse identify as a fall risk?
      A)Inguinal hernia
      B)Hyperlipidemia
      C)Hyperthyroidism
      D)Multiple sclerosis
    4. A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take?
      A)Leave the client to get help.
      B)Place the client in the prone position.
      C)Place a towel under the client's head.
      D)Hold the client's arms and legs still.
    Page 5 of 11

    Exam Review

    1. A nurse is assisting with an in-service about hospital-acquired injuries to a group of staff. Which of the following conditions should the nurse include in the teaching as an example of a hospital-acquired injury?
      A)Hypothyroidism
      B)Deep vein thrombosis
      C)Hypertension
      D)Diabetes mellitus
    2. A nurse is caring for a client who has a new prescription for metoclopramide 10 mg PO once a day. The medication available is in liquid form with a concentration of 1 mg/mL. How many milliliters of the medication should the nurse administer?
      A)5 mL
      B)15 mL
      C)1 mL
      D)10 ML
    3. A nurse is collecting data on a client who has an oral temperature of 39? C (102.2? F). Which of the following findings should the nurse expect?
      A)Decreased peripheral pulses
      B)Respiratory rate 10/min
      C)Dilated pupils
      D)Heart rate 108/min
    4. A nurse is performing a home safety assessment for a client who has experienced a stroke. Which of the following findings are a safety hazards for the client? (Select All that Apply.)(SATA)
      A)Area rugs are placed in the living room.
      B)Medications are stored in a clear bag
      C)The hot water heater is set at 54°C (130° F).
      D)Grab bars are installed in the bathroom.
      E)Dim lighting installed throughout the house.
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