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    Exam Review

    1. A postoperative patient complains of pain at the surgical site incision. Which of the following would be the priority action for the nurse to take?
      A)Observe the cardiac monitor for increased heart rate
      B)Ask the patient to rate the level of pain
      C)Assess the patient’s body language
      D)Inspect the incision site
    2. A nurse is assessing a client’s wound dressing and observes a watery red drainage. The nurse should document this drainage as which of the following?
      A)Sanguineous
      B)Serous
      C)Serosanguineous
      D)Purulent
    3. Which action should the nurse implement to help prevent thrombus formation in postsurgical patients?
      A)Maintain complete bed rest
      B)Place light wrapping on the legs and waist
      C)Encourage early ambulation
      D)Put pillows under the knees
    4. The nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding should the nurse expect?
      A)Blood pressure 148/92
      B)Abdominal distention
      C)Tenting of the skin
      D)Heart rate 62 beats/min
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    Exam Review

    1. In which patient will the nurse expect to see a positive Chvostek sign?
      A)A 24-year-old adult admitted for chronic alcohol abuse
      B)A 75-year-old patient admitted for a broken hip related to osteoporosis
      C)A 50-year-old patient admitted for acute hyperparathyroidism
      D)A 7-year-old child admitted for severe burns
    2. The nurse is caring for an obese patient who is suffering from fatigue related to ineffective breathing. Which intervention would be most appropriate to promote sleep?
      A)Stopping smoking immediately
      B)Running 30 minutes every morning
      C)Limiting the diet to 1500 calories a day
      D)Sleeping on two to three pillows at night
    3. The nurse is administering Ibuprofen (Advil) to an older patient. Which assessment data causes the nurse to hold the medication?
      A)Patient reports past medical history of gastric ulcer
      B)Patient reports last bowel movement was 2 days ago
      C)Patient states joint pain is 2/10 and intermittent
      D)Patient experiences respiratory depression after administration of an opioid medication
    4. The nurse is caring for an 84-year-old patient. Which finding would be expected?
      A)Decreased skin elasticity
      B)Increased muscle strength
      C)Enhanced night vision
      D)Improved short-term memory
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    Exam Review

    1. The nurse discovers a patient on the floor. The patient states that he fell out of bed. The nurse assesses the patient and places the patient back in bed. Which priority action should the nurse take next?
      A)Do nothing, no harm has occurred
      B)Notify the health care provider
      C)Assess the patient further
      D)Complete an incident report
    2. The group leader is overheard saying to a gathering of patients, “Focus on your breathing once again... Notice how it is regular.... Now focus on your left arm... Notice how relaxed your left arm feels... Notice the relaxation going down the left arm to the hand.” A patient asks the nurse what the group is doing. What is the nurse’s best response?
      A)It is imagery
      B)It is meditation
      C)It is group biofeedback
      D)It is progressive relaxation training
    3. The nurse is caring for a patient in the sleep lab. Which assessment finding indicates to the nurse that the patient is in stage 3 NREM?
      A)The patient is difficult to awaken
      B)The patient awakens easily
      C)The patient’s eyes rapidly move
      D)The patient’s vital signs are elevated
    4. The nurse is educating the family of a patient with expressive aphasia from a cerebral vascular accident (CVA/stroke). Which statement by the family best indicates teaching was effective?
      A)“We should carry a pen and a pad of paper around for communication.”
      B)“He will use the board with pictures to communicate with us nonverbally for now.”
      C)“We can expect him to recover full use of speech vocabulary in 1 day.”
      D)“It is important to thicken all his drinks to prevent aspiration.”
    Page 3 of 22

    Exam Review

    1. The nurse is turning a patient with a total hip replacement. Which of the following is the appropriate intervention?
      A)Keep the legs abducted with a pillow between them
      B)Flex the knee on the affected side
      C)Turn the patient to the affected side
      D)Changing the patient’s position
    2. Which of the following tasks could the RN delegate to the unlicensed assistive personnel (UAP)?
      A)Irrigate the NG tube with water that is connected to suction for a post-operative client
      B)Perform digital removal of stool on a client who is constipated
      C)Measure the amount of stool in the client’s colostomy bag
      D)Change the saturated central line dressing
    3. The nurse is educating the family of a patient with limited mobility after a hip fracture. Which action should the nurse take to help promote independence and self-care?
      A)Stress that older patients usually ask for help when needed
      B)Inform the family that placement in a nursing center is a permanent solution
      C)Provide information and answer questions as the patient and staff members make choices among care options
      D)Tell the family to enroll the patient in a ceramics class to maintain quality of life
    4. A patient with nocturia reports having to urinate 3 or 4 times each night. Which recommendation by the nurse is most appropriate?
      A)Limit fluid and caffeine intake before bed
      B)Practice Kegel exercises to strengthen bladder muscles
      C)Leave the bathroom light on to illuminate a pathway
      D)Clear the path to the bathroom of all obstacles before bedtime
    Page 4 of 22

    Exam Review

    1. A nurse is preparing to suction a patient with thick oral secretions. Which finding will cause the nurse to stop suctioning?
      A)Oxygen saturation 88%
      B)Blood pressure 132/88 mmHg
      C)Heart rate 110 bpm
      D)Respiratory rate 24 breaths/min
    2. A nurse is teaching the patient and family about wound care. Which technique will the nurse teach to best prevent transmission of pathogens?
      A)Wash hands
      B)Wear gloves
      C)Wash wound
      D)Wear eye protection
    3. The nurse is caring for a patient with swelling and redness following an ankle sprain. Which action by the nurse is most appropriate?
      A)Apply a warm compress to the ankle
      B)Elevate the ankle above heart level
      C)Encourage weight-bearing exercises
      D)Wrap the ankle tightly with a bandage
    4. A nurse is planning care for a client admitted with diarrhea. Which of the following interventions should be prioritized for this client?
      A)Use standard precautions when caring for client with diarrhea
      B)Monitor fluid intake and output fluid and electrolyte balance disturbances
      C)Encourage client to eat small, frequent meals frequently
      D)Identify cause of diarrhea and assess bowel habits
    Page 5 of 22

    Exam Review

    1. The nurse is caring for a newly admitted patient with urinary incontinence and impaired mobility. Which finding will the nurse expect?
      A)Tiny blood clots in the urine
      B)Skin irritation or redness in the perineal area
      C)Increased urinary frequency
      D)Decreased urine specific gravity
    2. For which patient would the use of the log rolling technique be indicated for repositioning the patient would?
      A)37-year-old patient after a neck surgery
      B)68-year-old patient with hypostatic pneumonia
      C)84-year-old patient with a stage IV sacral pressure ulcer
      D)54-year-old patient following a total knee replacement
    3. A nurse is caring for a client with left arm weakness. Which nursing action is most important to prevent contractures?
      A)Encourage deep breathing exercises
      B)Place the patient’s arm in a neutral position
      C)Perform passive range of motion exercises
      D)Increase oral fluid intake
    4. Which of the following nursing assessments would be the priority when considering the administration of pain medication to a client experiencing acute pain?
      A)Shallow breathing
      B)Blood pressure
      C)Pain intensity level
      D)Heart rate
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