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    Exam Review

    1. A nurse is caring for a client who is postoperative following repair of a right femur fracture. Exhibits Select 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing ▾ constipationdue to their ▾ oxycodone prescription.
      Dropdown 1:
      Option 1: dysrhythmias
      Option 2: constipation
      Option 3: impaired circulation
      Option 4: hypoglycaemia
      Option 5: hypovolemia
      Dropdown 2:
      Option 1: oxycodone prescription
      Option 2: neurovascular check
      Option 3: potassium level
      Option 4: glucose level
      Option 5: femur dressing
    2. A nurse is caring for a client who has a pressure injury. Exhibits
      (Highlight — findings requiring follow-up are marked)

      A nurse is caring for a client who has a pressure injury.

      Exhibits

      Click to highlight the documentation in the client's medical record that requires further action by the nurse. To deselect information, click on the information again.

      Day 4:

      Hydrocolloid dressing removed. Client has a 2.5 cm (1 in) x 3 cm (1.2 in) stage 3 pressure injury on left heal. Increased redness at wound borders and purulent drainage noted.

      Temperature 38.9° C (102° F)

      BP 118/56 mm Hg

      Heart rate 102/min

      Respiratory rate 22/min

      Pulse oximetry 95% on room air

      Hct 38% (37% to 47%)

      Hgb 12 g/dl (12 g/dL to 16 g/dL)

      WBC 12,000/mm (5,000 to 10,000 mm)

    3. A nurse is caring for a client who has bipolar disorder Exhibits Drag words from the choices below to fill in each blank in the following sentence. After assessing the client and reviewing the client's medical record, the nurse determines that the client could be experiencing which of the following? The client could be experiencing ▾ Lithium toxicityand ▾ Hypothyroidism.
      Dropdown 1:
      Option 1: Lithium toxicity
      Option 2: Hypothyroidism
      Option 3: hyperglycemia
      Option 4: acute kidney Injury
      Dropdown 2:
      Option 1: Lithium toxicity
      Option 2: Hypothyroidism
      Option 3: hyperglycemia
      Option 4: acute kidney Injury
    4. A nurse is preparing to administer vaccines to a 1-year-old child. Which of the following vaccines should the nurse give? (Select all that apply.)(SATA)
      A)Measles mumps rubella (MMR)
      B)Diphtheria, tetanus and acellular pertussis (DTaP)
      C)Varicella VAR
      D)Rotavirus RV)
      E)Human papillomavirus (HP
    Page 1 of 5

    Exam Review

    1. A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)(SATA)
      A)increased heart rate
      B)increased blood pressure
      C)Increased respiratory rate
      D)Increase hematocrit
      E)increased temperature
    2. A nurse is preparing to care for an 84-year-old male client who is being admitted to a medical unit from a provider's office. The nurse reviews the client's medical records to prepare the client's plan of care. Exhibits Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress
      ✓Elevate the head of the bed.
      ✓Encourage intake of low sodium diet
      ✓Heart Failure
      ✓urinary output
      ✓Blood pressure
      Actions to Take Choices
      ✓Elevate the head of the bed.
      ✕Teach the client signs of hyperglycemia.
      ✓Encourage intake of low sodium diet
      ✕Assess feet for sensation
      Potential Condition Choices
      ✕Anemia
      ✕Type 2 diabetes mellitus.
      ✓Heart Failure
      ✕Urinary tract infection
      Parameters to Monitor Choices
      ✓urinary output
      ✓Blood pressure
      ✕WBC count
      ✕Finger prick Blood glucose level
      ✕Hemoglobin
    3. A nurse is caring for an adolescent. Exhibits For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.
      AnticipatedNonessentialContraindicated
      Ambulate in hallway with supervision✓
      Ketorolac IV for pain✓
      Ice packs to affected area 15 min or 5 min off✓
      Meperidine for pain✓
      Intravenous fluids (IVF) at maintenance rate✓
      Oxygen in 2L/min via nasal cannula✓
    4. A nurse is caring for a client who is receiving continuous enteral feedings. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing ▾ dehydration .
      Dropdown 1:
      Option 1: Infection
      Option 2: tube displacement
      Option 3: absent gag refléx
      Option 4: fluid overload
      Option 5: dehydration
    Page 2 of 5

    Exam Review

    1. A nurse is caring for a 78-year-old client who was recently admitted from the emergency room and is reporting weakness. Exhibits Drag words from the choices below to fill in each blank in the following sentence The nurse has reviewed the client's medical record. The client is at risk for developing ▾ metabolic alkalosis and ▾ hypernatremia.
      Dropdown 1:
      Option 1: hypermagnesemia
      Option 2: hypervolemia
      Option 3: metabolic acidosis
      Option 4: hyperkalemia
      Option 5: hypernatremia
      Option 6: metabolic alkalosis
      Dropdown 2:
      Option 1: hypermagnesemia
      Option 2: hypervolemia
      Option 3: metabolic acidosis
      Option 4: hypernatremia
      Option 5: metabolic alkalosis
      Option 6: hyperkalemia
    2. A nurse is caring for a client who has terminal cancer and is receiving hospice care. Exhibits
      (Highlight — findings requiring follow-up are marked)

      A nurse is caring for a client who has terminal cancer and is receiving hospice care.

      Exhibits

      Click to highlight the information from the nurse's notes that indicate the client is actively dying.

      2000:

      Temperature 35.3° C (95.5°F)

      Heart rate 42/min

      Blood pressure 62/ min Hg palpated

      Called by family requesting visit to client. Client does not arouse to verbal, tactile, or painful stimulation. Cheyne-stokes breathing noisy respirations. Bowel sounds 4 quadrants. Family reports no urine output in last 4 hr. Skin intact.

      Family gathered around client. Update on client's condition provided.

    3. A nurse on a cardiac care unit is caring for a preschooler. Exhibits select words from the choices below to fill in each blank in the following sentence. The client is at risk for developing ▾ hypokalemia and ▾ digitalis toxicity.
      Dropdown 1:
      Option 1: hypertension
      Option 2: hypokalemia
      Option 3: digitalis toxicity
      Option 4: murmur
      Option 5: hypercyanotic spells
      Option 6: fever
      Option 7: dependent rubor
      Dropdown 2:
      Option 1: hypertension
      Option 2: hypokalemia
      Option 3: digitalis toxicity
      Option 4: murmur
      Option 5: hypercyanotic spells
      Option 6: fever
      Option 7: dependent rubor
    4. A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?
      A)Information about a client can be disclosed to family members at any time."
      B)"HIPAA established regulations of individually identifiable health information in verbal, electronic or written form.”
      C)“A client's address would be an example of personally identifiable information.”
      D)“HIPAA is a federal law, not a state law.”
    Page 3 of 5

    Exam Review

    1. A nurse is caring for a client who has heart failure and a prescription for digoxin 125 mcg PO daily. Available is digoxin PO 0.25 mg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
    2. A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)
      A)Perform a Glasgow Coma Scale assessment.4
      B)Establish IV access.3
      C)Open the airway using a jaw thrust maneuver.1
      D)Determine effectiveness of ventilator effort2
      E)Remove clothing for a thorough assessment.5
    3. A nurse is caring for a client on a medical-surgical unit. Exhibits Nurses Notes 0800: Client is admitted with a 3-day history of abdominal cramps and diarrhea of 4 to 5 liquid stools/day. Client was taking PO amoxicillin/clavulanate for a respiratory tract infection, 500 mg q12h for 10 days. Antibiotics completed 7 days ago. Bilateral breath sounds clear and present throughout. Abdomen soft, nondistended with hyperactive bowel sounds audible in 4 quadrants Stool contains mucous and is foul-smelling. Stool sent for culture.
      (Highlight — findings requiring follow-up are marked)

      A nurse is caring for a client on a medical-surgical unit.

      Exhibits

      Nurses Notes

      0800:

      Client is admitted with a 3-day history of abdominal cramps and diarrhea of 4 to 5 liquid stools/day.

      Client was taking PO amoxicillin/clavulanate for a respiratory tract infection, 500 mg q12h for 10 days. Antibiotics completed 7 days ago.

      Bilateral breath sounds clear and present throughout.

      Abdomen soft, nondistended with hyperactive bowel sounds audible in 4 quadrants

      Stool contains mucous and is foul-smelling.

      Stool sent for culture.

      Click to highlight the documentation in the client's medical record that requires further action by the nurse.

      Temperature 38.9° C (102°F)

      Blood pressure 118/56 mm Hg

      Heart rate 102/min

      Respirations 20/min

      Oxygen saturation 95% on room air

      Hermatocrit 47% (37% to 47%)

      Hemoglobin 16 g/dL (12 g/dL to 16 g/dL)

      Potassium 3.3 mEq/L (3.5 to 5.0 mEq/L)

      Stool culture positive for Clostridium difficile (negative)

    4. A nurse is caring for a client. Exhibits For each assessment finding, click to specify if the assessment finding is consistent with an arterial ulcer, a venous ulcer, or a diabetic ulcer. Each finding may support more than one disease process.
      Arterial ulcerVenous ulcerDiabetic ulcer
      +1 posterior tibial pulse✓✓
      Hair loss✓✓
      History of hypertension✓✓✓
      Pale wound bed✓✓
      Pain at ulcer site✓✓
      Defined edges✓✓
      Skin cool to touch of the affected extremity✓✓
    Page 4 of 5

    Exam Review

    1. A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)(SATA)
      A)Hypotension
      B)Polyuria
      C)Hyperthermia
      D)Absence of bowel sounds
      E)Weakened gag reflex
    2. A nurse is caring for a client. Exhibits A nurse is providing discharge teaching. Which of the following dient statements indicate an understanding of the teaching?
      UnderstandingNo understanding
      "My food will have to be the consistency of pudding.”✓
      "I won't be able to eat nuts anymore.”✓
      “I will have to stop watching television while I eat.”✓
      “I can have cream soups on this diet.”
      “I will look up at the ceiling when I swallow.”
      “I shouldn't drink liquids while I have food in my mouth."✓
    3. A nurse is caring for a client. Exhibits For each client finding, click to specify if the finding is consistent with Parkinson's disease, stroke, or multiple sclerosis. Each finding can support more than 1 disease process.
      Parkinson DiseaseStrokeMultiple Sclerosis
      Facial rigidity✓
      Speech✓✓✓
      Muscle movements✓
      Orientation status✓✓✓
      Ambulation pattern✓✓
    Page 5 of 5