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    Exam Review

    1. A nurse is caring for a client at the clinic. Exhibits Complete the following sentence by The client is at risk for ▾ Molar pregnancydue to▾ Hcg levels
      Dropdown 1:
      Option 1: Spontaneous abortion
      Option 2: Molar pregnancy
      Option 3: Induced abortion
      Dropdown 2:
      Option 1: Cervical dilatation
      Option 2: Hcg levels
      Option 3: Hemoglobin levels
    2. A charge nurse is teaching a newly licensed nurse about clients designating a health care proxy in situations that require a durable power of attorney for health care (DPAHC). Which of the following information should the charge nurse include?
      A)"The proxy should manage legal issues for the client."
      B)"The proxy can make treatment decisions if the client is under anesthesia."
      C)The proxy can make financial decisions if the need arises."
      D)The proxy should make health care decisions for the client regardless of the client's ability to do so "
    3. A nurse is caring for a newborn who is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse take?
      A)Provide frequent stimulation for the newborn.
      B)Encourage frequent eye contact with the newborn during feedings.
      C)Decrease the lighting levels in the nursery.
      D)Wrap the newborn loosely in a blanket
    4. A nurse is reviewing the medical record of a client who has a prescription for intermittent heat therapy for a foot injury. Which of the following findings should the nurse identify as a contraindication for heat therapy?
      A)Abdominal aortic aneurysm
      B)Phlebitis
      C)Osteoarthritis
      D)Peripheral neuropathy
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    Exam Review

    1. A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record?
      A)"Morphine 3.0 mg sub q every 4 hr PRN for pain."
      B)"Morphine 3 mg subcutaneous every 4 hr PRN for pain."
      C)"Morphine 3 mg SC q 4 hr PRN for pain."
      D)"Morphine 3 mg SQ every 4 hr PRN for pain."
    2. A nurse is obtaining a client's manual blood pressure and is having difficulty auscultating sounds. Which of the following actions should the nurse take?
      A)Apply the largest cuff available.
      B)Deflate the cuff quickly.
      C)Use the palpatory method to determine blood pressure.
      D)Place the arm above the level of the client's heart.
    3. A nurse enters a client's room and sees a small fire in the client's bathroom. Identify the sequence of steps the nurse should take. (Move the steps into the box, placing them in the order of performance. Use all the steps.)
      A)Activate the facility's fire alarm system.2
      B)Close all nearby windows and doors.3
      C)Use the unit's fire extinguisher to attempt to put out the fire.4
      D)Transport the client to another area of the nursing unit.1
    4. A nurse in an acute care facility is caring for a toddler. Exhibits For each assessment finding below, click to specify if the assessment finding is consistent with Crohn's disease, appendicitis, or intussusception. Each finding may support more than 1 disease process.
      Crohn's diseaseAppendicitisIntussusception
      Pain rating✓
      Vomiting✓✓
      Stool✓✓
      Temperature✓
      Abdominal findings✓
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    Exam Review

    1. A nurse is caring for a client who is obese. The client is crying and states, "Everyone is staring at me because of my weight." Which of the following responses should the nurse make?
      A)"How long have you struggled with your weight?"
      B)"Let's discuss some weight loss strategies that might work for you."
      C)"It sounds like you're saying that you feel uncomfortable around others."
      D)"Have you always felt uncomfortable being overweight?"
    2. A nurse is caring for a client who is postoperative following total hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation of the prosthesis?
      A)Raise the head of the client's bed to a high-Fowler's position.
      B)Keep an abduction pillow between the client's legs.
      C)Elevate the client's affected leg on a pillow when in bed.
      D)Position the client's knees slightly higher than the hips when up in a chair.
    3. 11. A nurse is caring for a client who has a tracheostomy and requires suctioning. Identify the sequence of steps the nurse should follow after applying sterile gloves. (Move the steps into the box, placing them in the selected order of performance. Use all the steps.)
      A)Withdraw the catheter 1 to 2 cm (0.4 to 0.8 in).3
      B)Insert the catheter until resistance is felt.2
      C)Lubricate the catheter with sterile saline.1
      D)Rotate the catheter while suctioning.4
    4. A nurse is caring for an 18-month-old toddler in the emergency department. Exhibits For each potential assessment finding, click to specify if the finding is consistent with Epiglottitis, Respiratory Syncytial virus, or Acute Streptococcal Pharyngitis. Each finding may support more than 1 disease process.
      EpiglottitisRespiratory Syncytial VirusAcute Streptococcal Pharyngitis
      Fever✓✓
      Exudate on pharynx✓
      Wheezing upon auscultation✓
      Drooling✓
      Hypoxia✓✓
      Tachypnea✓✓
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    Exam Review

    1. A nurse is caring for a client who is postoperative immediately following a cardiac catheterization with a right femoral approach. Which of the following actions should the nurse take?
      A)Assess the client's peripheral pulses every 15 min.
      B)Change the client's dressing 4 hr following the procedure.
      C)Instruct the client to flex the right knee every 30 min.
      D)Elevate the head of the client's bed to 45"
    2. A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states, "I don't know what to do. Everything has been happening so quickly." Which of the following responses by the nurse is therapeutic?
      A)"You should make sure your partner takes the prescribed medication."
      B)"You did the right thing by bringing your partner in for treatment."
      C)"Can you talk about what was happening with your partner at home?
      D)"Why do you think your partner's symptoms are progressing so quickly?"
    3. A nurse on a pediatric unit is caring for a preschooler who is postoperative following an appendectomy. Exhibits Complete the following sentence by using the lists of options. The child is at risk for developing ▾ Postoperative ileusas evidenced by their▾ Absent bowel sounds. and▾ Shallow respirations.
      Dropdown 1:
      Option 1: Atelectasis
      Option 2: Peritonitis
      Option 3: Postoperative ileus
      Option 4: Urinary retention
      Dropdown 2:
      Option 1: Absent bowel sounds
      Option 2: Clear breath sounds
      Option 3: Intact abdominal dressing
      Dropdown 3:
      Option 1: Intact abdominal dressing
      Option 2: Clear breath sounds
      Option 3: Shallow respirations
    4. A nurse is preparing a client for transfer to a long-term rehabilitation facility following a below-the-knee amputation of the right leg. Which of the following actions should the nurse take to protect the client's confidentiality?
      A)Provide a verbal report of the client's condition to the paramedic performing the transfer.
      B)Email the client's health information to the facility in an unencrypted file.
      C)Discuss the client's response to the transfer with another staff nurse.
      D)Fax the client's name and identifiable information to the rehabilitation facility
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    Exam Review

    1. A nurse is discussing effective communication techniques for a client who has visual impairment with a newly licensed nurse. Which of the following statements by the nurse indicates an understanding of the teaching?
      A)"I will use a communication board to assess the client's needs."
      B)“I will collaborate with a speech therapist about the client's plan of care."
      C)"I will use indirect lighting in the client's room."
      D)“I will use a loud tone of voice when speaking with the client.”
    2. A home care nurse is making a follow-up visit with a client who has COPD and is using a compressed oxygen system in his home. Which of the following actions should the nurse take?
      A)Have the client store smaller tanks under his bed.
      B)Place the oxygen tank away from curtains or drapes.
      C)Store the oxygen tank wrench in a locked cabinet.
      D)Ensure that the client checks the gauge weekly.
    3. A nurse is teaching a client about self-administration of sublingual nitroglycerin. Which of the following statements should the nurse include?
      A)"You should take a dose every night at bedtime."
      B)“You should take this medication with food."
      C)"You may repeat a dose after five minutes."
      D)“You may crush this medication if needed"
    4. A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make?
      A)"Rise slowly when getting out of bed "
      B)“Taking furosemide can cause you to be overhydrated."
      C)"Eat foods that are high in sodium."
      D)“Taking furosemide can cause your potassium levels to be high."
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    Exam Review

    1. A nurse is planning teaching for a client who has a newly implanted implantable cardioverter/defibrillator. Which of the following information should the nurse include?
      A)Wear loose-firing clothing.
      B)Return in two weeks for a follow-up MRI.
      C)Expect to have a rapid pulse rate for the first few weeks
      D)Resume tub baths and swimming after 24 hr
    2. A nurse is providing care for a client who is experiencing an acute exacerbation of systemic lupus erythematosus. Which of the following findings should the nurse anticipate?
      A)Diplopia
      B)Fever
      C)Esophagitis
      D)Bradykinesia
    3. A nurse is teaching the guardian of a 1-month-old infant about infant safety. Which of the following information should the nurse include in the teaching?
      A)Place a small, folded blanket behind the baby's neck to provide support while in the car seat.
      B)Anchor the car seat in a rear-facing position in the back seat of the vehicle.
      C)Ensure the water heater temperature is set to no more than 54° C (129.2° F
      D)Cover the baby with a cotton blanket when they are asleep.
    4. A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the client's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?
      A)Platelet count
      B)OPIT
      C)Fibrinogen level
      D)INR
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