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    Exam Review

    1. A nurse is caring for a client who is 2 days postoperative following abdominal surgery and has a prescription for opioid analgesia. Which of the following actions should the nurse implement to help facilitate the client's recovery?
      A)Administer naloxone if the client's respiratory rate is greater than 24/min.
      B)Provide analgesic medication prior to physical activities
      C)Inform the client to monitor for loose stools while taking opioid analgesia.
      D)Withhold analgesic medication unless the client reports pain.
    2. A nurse is teaching a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which manifestations should the nurse identify as the earliest indication of this complication?
      A)Generalized abdominal pain
      B)Cloudy effluent
      C)Increased heart rate
      D)Fever
    3. A nurse is providing discharge teaching to a client who will be self-administering insulin at home. Which of the following information should the nurse include regarding needle disposal?
      A)"Secure the cap tightly over the needle before you discard it."
      B)"Remove the needle from the syringe before you place it in the trash."
      C)"You can discard needles in an empty bleach bottle with a lid."
      D)"Place your storage container in a recycle bin when it is full."
    4. A nurse is caring for a client who reports feeling nauseous immediately following a procedure using moderate (conscious) sedation. Which of the following should be the nurse's priority action?
      A)Ensure suction equipment is available.
      B)Auscultate bowel sounds.
      C)Administer ondansetron.
      D)Turn the client on their side.
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    Exam Review

    1. A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of respiratory failure?
      A)Agitation
      B)Friction rub
      C)Xerostomia
      D)Decreased end-tidal CO2
    2. A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. The client reports bladder spasms and the nurse observes decreased urinary output. Which of the following actions should the nurse take?
      A)Decrease traction on the catheter.
      B)Remove the indwelling urinary catheter.
      C)Administer ibuprofen 400 mg for pain relief.
      D)Flush the catheter manually with 0.9% sodium chloride.
    3. A home health nurse is reviewing safety with the family of a client who uses home oxygen therapy. Which of the following information should the nurse include?
      A)Notify the fire department that oxygen is in use in the home.
      B)Store oxygen tanks on their side when not in use.
      C)Increase the oxygen flow rate by 1 L if the client experiences dyspnea.
      D)Replace cotton blankets with wool and synthetic blankets.
    4. A nurse is teaching a client who has burns to the upper body about positioning to prevent contractures. Which of the following information should the nurse include?
      A)"Place a firm pillow under your head."
      B)"Remain in a side-lying position."
      C)"Wear splints on your wrists."
      D)"Keep your elbow in a flexed position."
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    Exam Review

    1. A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include
      A)Request a prescription for a nightly sedative.
      B)Place the client's bed at the lowest height.
      C)Turn off all lights in the client's room at night.
      D)Assist the client with toileting at least once every 4 hr.
    2. A nurse is teaching a client who has a new prescription for montelukast to treat asthma. Which of the following statements by the client shows an understanding of the teaching?
      A)"I'll take this medication every day, even when I don't have symptoms."
      B)"I'll make sure I take these tablets on an empty stomach."
      C)"Once I take this for a while, I won't need my inhaler anymore."
      D)"I'll take this medication to stop wheezing when I have an attack."
    3. A nurse is caring for a client who takes lisinopril for hypertension. Which of the following client statements indicates an adverse effect of the medication?
      A)"I have to urinate frequently."
      B)"I have a heightened sense of taste."
      C)"I seem to be bruising more easily."
      D)"I have a nagging, dry cough."
    4. A nurse is assessing a client who has heart failure. Which of the following client statements should indicate to the nurse that the client needs referral for cardiac rehabilitation?
      A)"I'm too tired to brush my teeth."
      B)"I will weigh myself daily."
      C)"I hate how I feel all the time."
      D)"I need to start eating a low-sodium diet."
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    Exam Review

    1. A nurse is providing teaching for a client who has age-related macular degeneration. Which of the following information should the nurse include in the teaching?
      A)"You probably have a detachment of your retina."
      B)"A possible cause of this problem is a long-term lack of dietary protein."
      C)"You probably have noticed a decline in your central vision."
      D)"The doctor can perform surgery to correct this by repairing the folds in your retina."
    2. A nurse is assessing a client who has full-thickness burns. The nurse should identify that which of the following findings indicates the client's need for fluid resuscitation?
      A)Engorged neck veins
      B)Urine output 25 mL/hr
      C)1+ pitting peripheral edema
      D)Bilateral lung crackles
    3. A nurse is teaching a group of clients who have cancer about radiation therapy. Which of the following activities should the nurse include in the teaching?
      A)Limit socializing in large crowds.
      B)Decrease time spent outdoors.
      C)Decrease intake of fresh fruits or vegetables.
      D)Limit engaging in sport activities that can cause bruising.
    4. A nurse is preparing an in-service presentation about the use of automated external defibrillators (AEDs). Which of the following instructions should the nurse include in the teaching?
      A)"Use an AED for a client who has atrial fibrillation."
      B)"Set the AED to 80 joules."
      C)"Perform CPR while the AED is analyzing."
      D)"Position the client on a flat surface."
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    Exam Review

    1. A nurse is caring for a client who understands a prescribed surgical procedure, but cannot read or write. Which of the following actions should the nurse take?
      A)Inform a family member of the need to sign the consent.
      B)Allow the client to sign the consent with an X.
      C)Contact the client's power of attorney to sign the consent.
      D)Notify the surgical team that the client is unable to sign the consent.
    2. A nurse is caring for a client who had a thoracentesis 2 hr ago. Which of the following findings should the nurse expect?
      A)Increased lung expansion
      B)Dry, nonproductive cough
      C)Crepitus at the puncture site
      D)Rapid, shallow respirations
    3. A nurse is assessing a client. Which of the following findings indicates a fluid volume deficit?
      A)Elevated blood pressure
      B)Pitting edema
      C)Dyspnea
      D)Skin tenting
    4. A home health nurse is planning to use nonpharmacological pain relief measures for a client who has severe chronic back pain. Which of the following pain management guidelines should the nurse use?
      A)Distraction changes the client's perception of pain, but it does not affect the cause.
      B)Discontinue opioids before trying nonpharmacological methods of pain relief.
      C)Use imagery with clients who have difficulty with focus and concentration.
      D)Pain relief from the use of heat and cold continues for several hours after removal of the stimulus.
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    Exam Review

    1. A nurse is teaching a client who has diabetes mellitus about foot care. Which of the following instructions should the nurse include?
      A)"Wear loose-fitting slippers around the house."
      B)"Use a heating pad to keep your feet warm at night."
      C)"Wear cotton rather than nylon socks."
      D)"Wash your feet twice per day with antibacterial soap and hot water."
    2. A nurse is caring for a client who has hypervolemia. Which of the following is an expected assessment finding?
      A)Weight gain
      B)Hypotension
      C)Bradycardia
      D)Loss of skin turgor
    3. A nurse is caring for a client in the emergency department. For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS). Each finding may support more than 1 disease process.
      DKAHHS
      Creatinine greater than expected reference range✓✓
      Skin turgor✓✓
      Urine ketones✓
      Blood glucose greater than expected reference range✓✓
      Blood pH✓
    4. A nurse is caring for a client in the emergency department. The nurse is caring for the client in the ED. The nurse understands that the client is at risk of developing which of the following complications? Select all that apply.(SATA)
      A)Renal failure
      B)Cardiac arrhythmias
      C)Hypotension
      D)Septic shock
      E)Cerebral edema
      F)Respiratory alkalosis
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