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    Exam Review

    1. When assessing a client who had a transurethral resection of the prostate (TURP) one day ago, the nurse observes that his scrotum and penis are edematous. Which intervention(s) should the nurse implement? Select all that apply.(SATA)
      A)Put a pillow under the buttocks.
      B)Apply a cold pack to the scrotal and penile areas.
      C)Obtain a specimen for urinalysis.
      D)Remove the indwelling urinary catheter.
      E)Notify the healthcare provider immediately.
    2. During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?
      A)History of suicide attempts.
      B)Family history of schizophrenia.
      C)Undiagnosed social anxiety symptoms (SAD).
      D)Feelings of disorientation.
    3. The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?
      A)Severe motor dysfunction determines the extent of successful habilitation.
      B)Continued development of the brain lesion determines the child's outcome.
      C)Brain damage with CP is not progressive but does have a variable course.
      D)CP is one of the most common permanent physical disabilities in children.
    4. A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?
      A)Mix the next dose with food.
      B)Administer a half dose now.
      C)Withhold this dose.
      D)Give another dose.
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    Exam Review

    1. One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in this client's plan of care?
      A)Explain the need for skin exposure to sunlight without sunscreen.
      B)Teach the need for dietary and supplemental vitamin D.
      C)Instruct the client in the use of muscle strengthening exercises.
      D)Encourage progressive active range of motion.
    2. A client presents to the clinic with fatigue, poor appetite, general malaise, and vague joint pain that improves mid-morning. The client has been taking over-the-counter ibuprofen for several months. The healthcare provider makes an initial diagnosis of rheumatoid arthritis (RA). Which laboratory test(s) should the nurse report to the healthcare provider? Select all that apply.(SATA)
      A)Sedimentation rate
      B)Anti-cyclic citrullinated peptide (anti-CCP) antibodies
      C)D-Dimer
      D)C-reactive protein
      E)White blood cell count
    3. An older adult client who cares for her husband at home has just learned that she needs to have knee replacement surgery. She tells the nurse she is concerned about her inability to provide care to her husband while she recovers from surgery and attends physical therapy. She has a friend who can drive her to and from her appointments once she is discharged, but cannot provide the care her husband needs. How should the nurse respond to the client?
      A)Recommend that the client's family return to the area to help provide assistance.
      B)Advise to have a case management evaluation of the client's home environment.
      C)Suggest contacting social services to help find a respite care facility for her husband.
      D)Tell her to consider hiring a private nurse during the postoperative convalescence.
    4. In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?
      A)Nausea and headache.
      B)Increased fatigue.
      C)Yellow-tinged sputum.
      D)Watery diarrhea.
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    Exam Review

    1. A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?
      A)Monitor daily sodium intake.
      B)Measure ankle circumference.
      C)Obtain serum creatinine levels daily.
      D)Ensure client takes a diuretic every morning.
      E)None
      F)None
    2. While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?
      A)Sodium intake with meals and snacks affects the blood pressure.
      B)Hypotension leading to sudden shock can develop at any time.
      C)Elevated blood pressure must be anticipated and identified quickly.
      D)Blood pressure fluctuations mean that the condition has become chronic.
    3. A client is admitted during the acute phase of a stroke. The nurse observes that the client is restless and unable to follow instructions. Which instruction(s) should the nurse provide the unlicensed assistive personnel (UAP) who is assisting with the care of the client? Select all that apply.(SATA)
      A)Keep the room brightly lit while providing care.
      B)Minimize verbal interaction with the client.
      C)Monitor for change in speech.
      D)Avoid dropping side rails or abruptly closing the door.
      E)Report any change in level of consciousness.
    4. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Vital signs include a heart rate of 122 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 170/90 mm Hg. Which assessment finding warrants the most immediate intervention by the nurse?
      A)Yellow expectorated sputum.
      B)Oral temperature of 100.5°F (38.1°C).
      C)Bilateral diffuse wheezing.
      D)Shortness of breath on exertion.
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    Exam Review

    1. The nurse is planning discharge instructions for a client with type 2 diabetes mellitus who will be starting exenatide. Which information should be included in the discharge instructions?
      A)Inject exenatide within 30 minutes before or after a meal.
      B)Notify your healthcare provider if you start having abdominal pain.
      C)Exenatide acts in the same way as insulin in lowering blood glucose.
      D)There are no precautions about taking exenatide with other medications.
    2. The nurse is providing a nutrition class to a group of postmenopausal clients. Which food should the nurse emphasize to this group?
      A)Low fat yogurt.
      B)Mixed berries.
      C)Carrots.
      D)Beets.
    3. While caring for a toddler receiving oxygen via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?
      A)Apply petroleum jelly to the child's nose and lips.
      B)Use a topical lidocaine analgesic for cracked lips.
      C)Ask the mother what she usually uses on the child's lips and nose.
      D)Use a water soluble lubricant on affected oral and nasal mucosa.
    4. A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?
      A)Report the client's jaw pain to the healthcare provider.
      B)Advise the client to gargle with warm salt water twice daily.
      C)Determine how the client is administering the medication.
      D)Confirm that this is a common symptom of osteoporosis.
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    Exam Review

    1. The client who has emphysema and recently experienced a stroke receives a prescription for a metered-dose inhaler with a spacer device. The client asks the nurse if using the spacer is necessary. Which information should the nurse provide?
      A)It allows time to inhale the entire dispensed dose.
      B)It prevents mouth infections when an inhaler is used.
      C)It allows the medication to slowly enter the lungs.
      D)It increases the effectiveness of the medication.
    2. A client with chronic obstructive pulmonary disease (COPD) is experiencing worsening dyspnea and low oxygen levels. The vital signs are assessed as a temperature of 99.6°F (37.5°C), heart rate 98 beats/minute, respirations 28 breaths/minute, blood pressure 140/82 mm Hg, and an oxygen saturation 88% on room air. Which action should the nurse implement?
      A)Prepare client for endotracheal intubation.
      B)Apply a nonrebreather mask at 100% oxygen.
      C)Place the client in a forward-leaning position.
      D)Obtain a sputum sample for culture and sensitivity.
    3. The nurse is caring for a client who has a history of experiencing delusions. The client describes singing in a concert in the afternoon for thousands of people. Which action should the nurse take?
      A)Attempt to comfort the client by agreeing with the delusions and ask open-ended questions.
      B)Present a personal perception of reality in a nonconfrontational manner.
      C)Disagree with the statement and set clear limits on talking about it.
      D)Immediately inform the healthcare provider that the client is experiencing a delusional episode.
    4. The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?
      A)Ear pain and fever.
      B)Elevated WBC and sedimentation rate.
      C)Positive Epstein-Barr, and malaise.
      D)Increased BUN and serum creatinine.
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    Exam Review

    1. The nurse is teaching a female client about preventive measures for urinary tract infections (UTI). Which information should the nurse include?
      A)Hold urine for at least 10 minutes to dilute bacteria.
      B)Empty the bladder before and after sexual intercourse.
      C)Drink large amounts of fluids before bedtime.
      D)Cleanse the perineal area in a circular motion after voiding.
    2. An adult is admitted with acute flank pain, a 102°F (38.9°C) oral temperature, hematuria, dysuria, urgency, and fishy-smelling urine. Which admitting prescription(s) are most important for the nurse to implement? Select all that apply.(SATA)
      A)Obtain clean catch urine for culture and sensitivity.
      B)Initiate broad spectrum IV antibiotic as secondary infusion.
      C)Collect a serum sample for hemoglobin and hematocrit.
      D)Give diphenhydramine prep for intravenous pyelogram.
      E)Force oral fluids to 2,000 mL/24 hours.
    3. The nurse is developing a plan of care for an older male client with type 2 diabetes who reports blurred vision. Which outcome should the nurse include in the plan of care for this client?
      A)The client's family will state signs and symptoms about the disease.
      B)The client will express acceptance of his changing health status.
      C)The nurse will demonstrate the procedure for accurate eye care.
      D)The client's daily blood pressure will be less than 140/80 mm Hg this month.
    4. Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?
      A)An adult who is one day postoperative for a laparoscopic cholecystectomy.
      B)An older client who is one day postoperative with a colostomy for colon cancer.
      C)An older adult who is scheduled for foot amputation due to diabetes complications.
      D)An adult with alcoholism, cirrhosis, and hepatic encephalopathy.
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