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    Exam Review

    1. A nurse on a medical-surgical unit is admitting a client. Exhibits
      (Highlight — findings requiring follow-up are marked)

      A nurse on a medical-surgical unit is admitting a client.

      Exhibits

      Click to highlight the action that would be appropriate for the care of the client. Each body system may support more than 1 potential action. To deselect an action, click on the action again.

      Body System

      Action

      Cardiopulmonary

      Inform client to achieve two to four breaths per session when using incentive spirometer.

      Encourage deep-breathing exercises.

      Check for pain.

      Gastrointestinal

      Encourage the client to increase fiber in their diet.

      Promote intake of oral fluids.

      Apply barrier ointment after bowel movements.
    2. A nurse is planning care for a client who was admitted to the unit for pneumonia. Exhibits The nurse is planning care for the client. Complete the following sentence by using the lists of options. After providing perineal care and donning sterile gloves, the nurse should first ▾ lubricate the catheter tipfollowed by▾ insert the catheter until urine flows
      Dropdown 1:
      Option 1: lubricate the catheter tip
      Option 2: insert the catheter until urine flows
      Dropdown 2:
      Option 1: lubricate the catheter tip
      Option 2: insert the catheter until urine flows
    3. A nurse is caring for a client who had a stroke. Exhibits Complete the following sentence using the lists of options. The client is at risk for developing ▾ deep vein thrombosis (DVT)due to their▾ immobility
      Dropdown 1:
      Option 1: deep vein thrombosis (DVT)
      Option 2: immobility
      Dropdown 2:
      Option 1: deep vein thrombosis (DVT)
      Option 2: immobility
    4. A nurse in a medical-surgical unit is caring for 6 clients. Exhibits Complete the following sentence by using the lists of options. The first client the nurse should assess is ▾ Pulmonary edemafollowed  by▾ Hip fracture
      Dropdown 1:
      Option 1: Pulmonary edema
      Option 2: Glycemic control
      Option 3: Hypoalbuminemia
      Dropdown 2:
      Option 1: Hip fracture
      Option 2: Low potassium
      Option 3: Malnutrition
    Page 1 of 18

    Exam Review

    1. A nurse is caring for a client who is postoperative. Exhibits
      (Highlight — findings requiring follow-up are marked)

      A nurse is caring for a client who is postoperative.

      Exhibits

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

      Temperature 37.5° C (99.5° F)

      Client is difficult to arouse.

      Respiratory rate 10/min

      Pulse oximetry 88% on room air (95% to 100%)

      Pupils are 3 mm, equal, and reactive to light.

      Blood pressure 99/46 mm Hg

      Heart rate 61/min

    2. A nurse is caring for an older adult client newly admitted to the medical unit. Exhibits
      (Highlight — findings requiring follow-up are marked)

      A nurse is caring for an older adult client newly admitted to the medical unit.

      Exhibits

      Click to highlight the pieces of information that indicate the client is at risk for falls. To deselect a piece of information, click on that piece of information again.

      Nurses' Notes

      1000:

      An older adult client admitted following a fall down approximately five steps. Client's partner reports client possibly hit their head and was a little disoriented for a minute or two. Client states, "I feel fine. I just slipped." Client has a history of falls and orthostatic hypotension per client's partner. Client uses a walker and wears rubber-soled slippers at home. Client ordered new glasses following an eye exam last week but has not received them yet. Partner states they both do exercises that focus on coordination, three times per week.

      Vital Signs

      1000:

      Temperature 37° C (98.6° F)

      Heart rate 72/min Respiratory rate 20/min

      Blood pressure

      Lying: 130/90 mm Hg

      Sitting: 128/88 mm Hg

      Standing: 98/60 mm Hg

      Oxygen saturation 97% on room air

    3. A nurse is caring for a client on a medical surgical unit. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The nurse should first follow up on the client's▾ oxygen saturation and▾ behavioral findings
      Dropdown 1:
      Option 1: oxygen saturation
      Option 2: pain
      Option 3: WBC count
      Option 4: behavioral findings
      Option 5: bowel findings
      Dropdown 2:
      Option 1: oxygen saturation
      Option 2: pain
      Option 3: WBC count
      Option 4: behavioral findings
      Option 5: bowel findings
    4. A nurse is caring for a client. Exhibits Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing ▾ Constipationdue to▾ Opioid use
      Dropdown 1:
      Option 1: Confusion
      Option 2: Pressure injuries
      Option 3: Hypoglycemia
      Option 4: Constipation
      Option 5: Dysrhythmias
      Dropdown 2:
      Option 1: Opioid use
      Option 2: Potassium level
      Option 3: IV dexrose
      Option 4: Sodium level
      Option 5: Immobility
    Page 2 of 18

    Exam Review

    1. A nurse is caring for a client in a medical-surgical unit. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The client is most at risk of developing ▾ atelectasisand▾ atelectasis
      Dropdown 1:
      Option 1: urinary tract infection
      Option 2: delayed wound
      Option 3: healing
      Option 4: deep vein thrombosis
      Option 5: atelectasis
      Option 6: paralytic ileus
      Dropdown 2:
      Option 1: urinary tract infection
      Option 2: delayed wound
      Option 3: healing
      Option 4: deep vein thrombosis
      Option 5: atelectasis
      Option 6: paralytic ileus
    2. A nurse is providing teaching to an older adult client about factors that increase the risk of urinary tract infection. Which of the following information should the nurse include?
      A)Bladder capacity decreases in older adults.
      B)The urethral sphincter functions less efficiently.
      C)Decreased bladder tone can cause urinary retention.
      D)The ability to concentrate urine decreases.
    3. A charge nurse is teaching a group of newly licensed nurses about the health risks for family caregivers of clients who are chronically ill. Which of the following should the nurse include as placing a family caregiver at risk?
      A)Previous caregiver experience
      B)25 to 50 years of age
      C)Lives in a different dwelling than the client
      D)Providing care for greater than 1 year
    4. A nurse is preparing a client who has a latex allergy for surgery. Which of the following actions should the nurse plan to take?
      A)Use IV tube ports when injecting medications.
      B)Remove medication from multi-dose vials with the stopper in place.
      C)Secure loose cords in stockinette with tape.
      D)Schedule the client's surgery as the last procedure of the day.
    Page 3 of 18

    Exam Review

    1. A nurse is caring for a group of clients. Which of the following actions by the nurse demonstrates client advocacy?
      A)Submitting an incident report to risk management following a client fall
      B)Documenting the effectiveness of pain medication in the client's health record
      C)Asking another nurse to check a medication calculation for a client
      D)Informing the family of a deceased client of the client's wish to be an organ donor
    2. A nurse is teaching a client about prevention of injury when lifting. Which of the following instructions should the nurse include in the teaching?
      A)"A narrow base of support is recommended for effective lifting."
      B)"Make sure to bend at the waist when lifting objects more than 30 pounds."
      C)"Use a twisting motion when moving objects to prevent back strain."
      D)"Stand close to a heavy object before attempting to lift it."
    3. A community health nurse is visiting an older adult client who recently moved into an assisted living apartment. Which of the following client statements indicates difficulty accepting their transition?
      A)"The food is not great, but it is nice not having to do all of my own cooking."
      B)"When I go out, I've been using public transportation since I can't drive anymore."
      C)"I don't want to go to the activity room because none of the other residents can hear."
      D)"The staff sometimes have to remind me to use a cane when I walk in the hall."
    4. A nurse is performing a dressing change on a client and observes granulation tissue. Which of the following findings should the nurse document?
      A)Translucent, red tissue
      B)Soft, yellow tissue
      C)Stringy, white tissue
      D)Thick, black tissue
    Page 4 of 18

    Exam Review

    1. A nurse is teaching a group of students about the components of informed consent. Which of the following should the nurse include?
      A)The client cannot change their mind after signing consent.
      B)The alternative treatments to the procedure should be explained.
      C)The time of the procedure should be indicated on the form.
      D)The charge nurse should review the form once it's signed.
    2. A nurse is reviewing a medication prescription that reads, "Morphine 5 mg IV bolus for pain". Which of the following components should the nurse clarify with the provider?
      A)Dose
      B)Time
      C)Medication
      D)Route
    3. A nurse is discussing community support services with an adult client who has cognitive disabilities and their guardian. The guardian reports that the client's need for help with activities of daily living has increased recently. Which of the following referrals is most important to promote the client's quality of life?
      A)Community health nurse
      B)Respite care provider
      C)Dietician
      D)Occupational therapist
    4. A nurse is teaching a group of nurses about client confidentiality. Which of the following statements made by a nurse indicates an understanding of the teaching?
      A)"I can discuss client information in the hallway outside a client's room."
      B)"I will need permission from a client to share health information with a relative."
      C)"I can share a client's diagnosis with any member of the health care team."
      D)"I will need written permission from the provider to allow a client to access their electronic medical record."
    Page 5 of 18

    Exam Review

    1. A nurse manager is evaluating a nurse who is performing a urinary catheterization on a male client. Which of the following actions by the nurse demonstrates correct aseptic technique?
      A)Grasps the catheter 10.16 to 12.7 cm (4 to 5 in) from the tip
      B)Cleanses the meatus using a clean cotton ball
      C)Cleanses the meatus from the center in a circular motion
      D)Applies clean gloves before beginning the procedure
    2. A nurse is caring for a client who is receiving a first dose of amoxicillin. Which of the following findings should the nurse report to the provider immediately?
      A)High-pitched wheezing
      B)Urticaria over the entire body
      C)Pruritis of the face
      D)Rhinitis with clear discharge
    3. A nurse is caring for a client who was admitted for an exacerbation of their COPD. The client will be discharged with a new prescription for oxygen therapy and will need assistance with activities of daily living. Which of the following referrals should the nurse obtain for the client?
      A)Case manager
      B)Hospice care facility
      C)Long term care facility
      D)Pharmacist
    4. A nurse is planning to provide discharge teaching to a client who speaks a different language than the nurse. Which of the following actions should the nurse take?
      A)Consider gender and age when selecting an interpreter.
      B)Direct comments and questions to the interpreter.
      C)Speak to the client in a loud voice.
      D)Ask a member of the client's family to serve as an interpreter.
    Page 6 of 18