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    Exam Review

    1. An adult is admitted to the cardiac care unit for observation. Telemetry indicates that premature ventricular contractions (PVCS) are occurring sporadically. Which activity associated with the T wave makes PVCs particularly dangerous when they coincide with this waveform?
      A)Atrial contraction.
      B)Maximum ventricular emptying.
      C)Depolarization.
      D)Repolarization.
    2. An adolescent is admitted to the hospital because of a suicide attempt with an overdose of acetaminophen. Which blood values are most important for the nurse to monitor during the first 72 hours following ingestion of this overdose?
      A)Arterial blood pH, pC02, oxygen saturation.
      B)White blood count, hemoglobin, hematocrit.
      C)Lactic dehydrogenase (LD), alanine amniotransferase (ALT), aspartaamniotransferase (AST)
      D)Blood urea nitrogen, creatinine, specific gravity.
    3. An obese female client with a high serum cholesterol level comes to the clinic for a follow-up evaluation. She tells the nurse that she is now walking 30 minutes three times per week and is eating a carbohydrate-free, high-protein diet to lose weight. What response would be best for the nurse to provide?
      A)Praise the client for her exercise and dieting efforts and encourage her to continue with this program.
      B)Teach the client additional ways to lower cholesterol, including stress management.
      C)Explain to the client that her diet choice is not helpful in lowering cholesterol levels.
      D)Discuss the importance of maintaining a target heart rate during each exercise period.
    4. The nurse makes a supervisory home visit to observe an unlicensed assistive personnel (UAP) who is providing personal care for a client with Alzheimer's Disease. The nurse observes that whenever the client gets upset, the UAP changes the subject. What action should the nurse take in response to this observation?
      A)Assume care of the client to ensure that effective communication is maintained.
      B)Tell the UAP to offer more choices during the personal care to prevent anxiety.
      C)Affirm that the UAP is using an effective strategy to reduce the client's anxiety.
      D)Meet with the UAP later to role model more assertive communication techniques.
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    Exam Review

    1. A child is admitted to the hospital with diarrhea and vomiting. Potassium chloride is prescribed for inclusion with rehydration IV fluids. Prior to administering the potassium, the nurse should ensure that which condition exists?
      A)The client has had no cardiac arrhythmias in the last 24 hours.
      B)The oxygen saturation level per pulse oximeter is greater than 95%.
      C)The client has stopped vomiting before the potassium is added to the IV fluids.
      D)The client is able to void, assuring kidney function is present.
    2. A multigravida, full-term, laboring client complains of "back labor." Vaginal examination reveals that the client's cervix is dilated 3 cm with 50% effacement, and the fetal head is at -1 station. Which action should the nurse implement?
      A)Ambulate the client between contractions.
      B)Turn the client to a lateral position.
      C)Notify the scrub nurse to prepare the operating room.
      D)Apply counter-pressure to the sacral area.
    3. Which assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin?
      A)Auscultation of breath sounds.
      B)Bladder palpation.
      C)Inspection of the mouth.
      D)Blood glucose monitoring.
    4. A client at the healthcare clinic reports a new onset of pyrosis and dyspepsia to the nurse. Which nursing action has the highest priority?
      A)Recommend the use of antacids to control symptoms.
      B)Provide reassurance that these are common symptoms of reflux disease.
      C)Instruct the client about the symptoms of reflux disease.
      D)Schedule an appointment for a physical examination.
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    Exam Review

    1. The unlicensed assistive personnel (UAP) who is caring for a postoperative client reports to the charge nurse that the client is not using the incentive spirometer effectively. Which action should the charge nurse implement?
      A)Encourage the UAP to demonstrate the effective use of the incentive spirometer to the client.
      B)Schedule time later in the morning to review the use of the incentive spirometer with the client.
      C)Ask the practical nurse assigned to care for the client to review the use of the spirometer with the client.
      D)Advise the UAP that the respiratory therapist is responsible to supervise the client's use of the spirometer.
    2. The healthcare provider prescribes oxytocin synthetic 10 units/L via IV drip to augment a client's labor because she is experiencing a prolonged active phase. Because the client is receiving oxytocin, the nurse should closely monitor for which complication?
      A)Fetal tachycardia.
      B)Hemorrhage.
      C)Uterine tetany.
      D)Uterine hypostimulation.
    3. The charge nurse observes an unlicensed assistive personnel (UAP) preparing to use a standard sized blood pressure cuff to measure the blood pressure of an adult client with thrombocytopenia. Which action should the charge nurse take?
      A)Ask the client's primary nurse to measure the vital signs rather than the UAP.
      B)Observe the technique of the UAP in measuring the client's blood pressure.
      C)Advise the UAP that the client is at risk for excessive bleeding and bruising.
      D)Instruct the UAP to use a smaller blood pressure cuff to prevent injury.
    4. A client who had a left above knee amputation (AKA) two days ago has a soft stump dressing in place. To prevent the development of a contracture on the left leg, which intervention should the nurse implement?
      A)Position the client prone 3 to 4 times a day.
      B)Elevate the client's left leg on two pillows at all times.
      C)Turn the client to the unaffected side only.
      D)Instruct the client to push the stump against a soft pillow.
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    Exam Review

    1. A client who has a serum potassium level of 5.9 mEq/L (5.9 mmol/L) tells the nurse of deciding to leave the hospital, even though the healthcare provider has not discharged the client. The client states, "I do not care if I am not discharged, I do not want any more treatment." It is most important for the nurse to ensure that the client understands which fact prior to leaving the facility? Reference range
      A)Potassium (K+) [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]
      B)The client should know they can return to the hospital at any time for treatment.
      C)Inform the client that insurance will not pay for this hospital stay if the client leaves against medical advice.
      D)Explain to the client that their condition is extremely serious and that the client could die as a result of this decision.
    2. During discharge teaching, a parent asks why the premature infant should get monthly injections of palivizumab. Which information should the nurse provide?
      A)This drug protects the premature infant from respiratory syncytial virus (RSV).
      B)This medication provides surfactant, which helps the lungs mature more quickly.
      C)These injections prevent retinopathy of prematurity caused by high levels of oxygen.
      D)Monthly injections promote normal neurological and physical development.
    3. A client who is 4-days postpartum calls the clinic and reports to the nurse that her nipples are so sore that she does not know if she can continue to breastfeed her infant. Which instruction is best for the nurse to provide?
      A)Apply hot packs just before each feeding.
      B)Allow the nipples to rest by supplementing with formula every other feeding.
      C)Wash the nipples with soap to prevent infection from occurring.
      D)Let the nipples air dry thoroughly after each feeding.
    4. A client receives a prescription for permethrin to treat an infestation of scabies. The nurse instructs the client to massage the cream into the skin from the head to the soles of the feet, avoiding the eyes. Which additional instruction should the nurse provide?
      A)Shower or bathe 8 to 14 hours after treatment to remove cream.
      B)Remove the cream from the skin immediately if pruritis occurs.
      C)Avoid areas between fingers and toes during application.
      D)Reapply cream in seven days to prevent reinfestation.
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    Exam Review

    1. A primigravida at 36-weeks gestation, who is Rh negative, experienced abdominal trauma in a motor vehicle collision. Which assessment finding is most important for the nurse to report to the healthcare provider?
      A)Fetal heart rate of 162 beats/minute.
      B)Mild contractions every 10 minutes.
      C)Trace of protein in the urine.
      D)Positive fetal hemoglobin testing.
    2. The nurse notices a reddened area on the coccyx of a client who is wheelchair bound. Which intervention should the nurse implement?
      A)Encourage the client to shift weight while sitting.
      B)Ask the team leader to document the assessment findings.
      C)Provide a donut shaped cushion for the client to use
      D)Carefully rewash the site and apply a hydrocolloid patch.
    3. The nurse is receiving report for a laboring client who arrived in the emergency center with ruptured membranes that the client did not recognize. Which is the priority nursing action to implement when the client is admitted to the labor and delivery suite?
      A)Monitor amniotic fluid for meconium.
      B)Take the client's temperature.
      C)Prepare to start an IV.
      D)Begin a pad count.
    4. The nurse is evaluating discharge teaching of an adolescent who had a long leg plaster cast applied in the emergency department. Which statement by the adolescent indicates an understanding of cast care?
      A)"I will not be able to take a shower until the cast is removed from my leg."
      B)"If my toes are tingling I will elevate my leg above my heart, on several pillows."
      C)"I should wrap a cloth around a stick before using it to scratch under my cast."
      D)"I will put adhesive tape around the edges of the cast if they become sharp."
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    Exam Review

    1. A client who gave birth 48 hours ago has decided to bottle feed the infant. During the assessment, the nurse observes that both breasts are swollen, warm, and tender on palpation. Which instruction should the nurse provide?
      A)Run warm water over breasts.
      B)Express small amounts of milk from the breasts to relieve pressure.
      C)Apply ice to the breasts for comfort.
      D)Wear a loose-fitting bra during the day to prevent nipple irritation.
    2. A male client who had a transurethral resection of the prostate (TURP) today has a continuous bladder irrigation (CBI). The client requests pain medication for abdominal pain rated at "9" on a scale of 0 to 10. Which action should the nurse take first?
      A)Assist him to ambulate to help pass flatus.
      B)Palpate his abdomen and check his urinary output.
      C)Position him on the left side and slow the irrigation rate.
      D)Administer the prescribed PRN analgesic medication.
    3. When planning home care for a child with juvenile rheumatoid arthritis (JRA), which recommendation should the nurse provide to the child's parents?
      A)Encourage the child to decrease motion of affected joints for one hour before bedtime.
      B)Exercise joints every morning before assisting the child out of bed.
      C)Upon awakening, complete exercise program immediately then follow with a hot shower.
      D)Place the child in a warm bath every morning before any activity.
    4. The nurse assigns an unlicensed assistive personnel (UAP) to take the vital signs of a client who is positive for HIV. Which personal protective equipment (PPE) should the nurse direct the UAP to use when obtaining this client's vital signs?
      A)Gloves only.
      B)Gloves and mask.
      C)Gown, gloves, mask.
      D)PPE not required.
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