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    Exam Review

    1. A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?
      A)Assess pupillary response to light hourly.
      B)Initiate seizure precautions.
      C)Measure urinary output every hour.
      D)Monitor serum potassium frequently.
    2. A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?
      A)Assess pupillary response to light hourly.
      B)Initiate seizure precautions.
      C)Measure urinary output every hour.
      D)Monitor serum potassium frequently.
    3. 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 health care provider?
      A)Yellow-tinged sputum
      B)Nausea and headache
      C)Watery diarrhea
      D)Increased fatigue
    4. A male client reports to the on-call clinic nurse that he took two tablets of 10 mg lisinopril by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any chest pain at the moment or recently. Which action should the nurse take?
      A)Instruct the client to increase his intake of oral fluids until the skin flushing is relieved.
      B)Advise the client to place one nitroglycerin tablet under his tongue as a precaution.
      C)Tell the client to have someone bring him to an emergency department immediately.
      D)Reassure the client that facial flushing is a common side effect of the medication.
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    Exam Review

    1. A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take?
      A)Secure chest tube to the stretcher for transport.
      B)Administer PRN pain medication prior to transport.
      C)Mark the amount of chest drainage on the container.
      D)Keep chest tube container below the site of insertion.
    2. 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)Administer a half dose now.
      B)Give another dose.
      C)Mix the next dose with food.
      D)Withhold this dose.
    3. Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?
      A)Observe insertion site.
      B)Palpate flank area.
      C)Measure abdominal girth.
      D)Assess perineal area.
    4. A client is receiving continuous ambulatory peritoneal dialysis since the arteriovenous (AV) graft in the right arm is no longer available for use for hemodialysis. The client has lost weight, has increasing peripheral edema, and has a serum albumin level of 1.5 g/dL (15 g/L). Which intervention is the priority for the nurse to implement? Serum Albumin Reference Range: 3.5 to 5.5 g/dL (35 to 55 g/L)
      A)Recommend the use of support stockings to enhance venous return
      B)Ensure the client receives frequent small meals containing complete proteins
      C)Evaluate patency of the AV graft for resumption of hemodialysis
      D)Instruct the client to continue to follow the prescribed rigid fluid restriction amounts
    Page 2 of 30

    Exam Review

    1. Text 1:The nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease. Which statement(s) made by the client should the nurse recognize as needing additional education? (Select all that apply.)(SATA)
      A)Consume foods with saturated fats.
      B)Walk 30 minutes per day.
      C)Use a salt substitute.
      D)Keep a food diary.
      E)Eat more canned vegetables.
      F)Include oatmeal for breakfast.
    2. A 6-week-old infant with poor weight gain is scheduled for a pyloromyotomy. Which pre-operative nursing action has the highest priority?
      A)Mark an outline of the "olive-shaped" mass in the right epigastric area.
      B)Maintain a continuous infusion of IV fluids per prescription.
      C)Monitor amount of intake and infant's response to feedings.
      D)Instruct parents regarding care of the incisional area.
    3. Two days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects the client had a pulmonary embolus. Which action should the nurse take first?
      A)Notify the healthcare provider.
      B)Prepare a continuous heparin infusion per protocol.
      C)Provide supplemental oxygen.
      D)Bring the emergency crash cart to the bedside.
    4. When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?
      A)When the client has ankle edema.
      B)If the client has an elevated blood pressure.
      C)During admission to labor and delivery.
      D)Within the first trimester of pregnancy.
    Page 3 of 30

    Exam Review

    1. A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which pre-operative nursing action has the highest priority?
      A)Mark an outline of the "olive-shaped" mass in the right epigastric area.
      B)Instruct parents regarding care of the incisional area.
      C)Monitor amount of intake and infant's response to feedings.
      D)Initiate a continuous infusion of IV fluids per prescription.
    2. The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection?White Blood Cell (WBC. Reference Range: 5000-10,000/mm^3 (5-10 x 10^9/L)
      A)Moderate amount of foul-smelling lochia.
      B)Blood pressure of 122/74 mm Hg
      C)Oral temperature of 100.2°F (37.9°C..
      D)White blood cell count of 19,000/mm^3 (19 x 10^9/L)
    3. A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which pre-operative nursing action has the highest priority?
      A)Mark an outline of the "olive-shaped" mass in the right epigastric area.
      B)Instruct parents regarding care of the incisional area.
      C)Monitor amount of intake and infant's response to feedings.
      D)Initiate a continuous infusion of IV fluids per prescription.
    4. What environmental factor is most significant when planning care for a client with osteomalacia?
      A)Quiet, calm surroundings
      B)Stimulating sounds and activity
      C)Cool, moist air
      D)Adequate sunlight
    Page 4 of 30

    Exam Review

    1. The nurse is educating a client about essential hypertension prevention. Which information should the nurse provide? (Select all that apply.)(SATA)
      A)Alcohol consumption will not produce vascular changes.
      B)Sodium intake can be regulated by limiting canned foods in the diet.
      C)Salt substitutes can help with maintaining a healthy diet.
      D)Weight management is promoted by taking daily walks for thirty minutes.
      E)Blood pressure readings should be taken at noontime.
      F)Uncontrolled hypertension can lead to renal damage.
    2. Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD.?
      A)Blood pressure, heart rate, and temperature.
      B)Leukocytes, neutrophils, and thyroxine.
      C)Serum potassium, calcium, and phosphorus.
      D)Erythrocytes, hemoglobin, and hematocrit.
    3. The charge nurse observes a new nurse during the administration of two different liquid medications at once through a gastrostomy tube used for enteral feeding. The charge nurse observes the new nurse's actions. What action(s) should the charge nurse take? (Select all that apply.)(SATA)
      A)Encourage the novice to flush the tube with more water.
      B)Instruct the novice to administer each medication separately.
      C)Add the liquid volumes when documenting fluid intake.
      D)Confirm that the novice determined the amount of gastric residual.
      E)Advise the novice to use the plunger when giving medications.
    4. Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?
      A)Measure abdominal girth
      B)Assess perineal area
      C)Observe insertion site
      D)Palpate flank area
    Page 5 of 30

    Exam Review

    1. The daughter of an older woman who has Parkinson's disease, calls the clinic and reports that her mother has been confused for the past week. Which action(s) should the nurse take? (Select all that apply.)(SATA)
      A)Determine if the mother has recently experienced a fall.
      B)Review the client's current food and medication allergies.
      C)Encourage increased intake of high-protein foods.
      D)Instruct the daughter to check her mother's temperature.
      E)Ask if the mother is experiencing any pain with urination.
    2. Which nursing intervention is most important for the nurse to include in the plan of care for a client with alcohol withdrawal delirium?
      A)Maintain a quiet, non-stimulating environment.
      B)Force oral fluids and provide frequent small meals.
      C)Confront the client's denial of substance abuse.
      D)Encourage attendance and group participation.
    3. The nurse is preparing a 4-day-old infant with a serum bilirubin level of 19 mg/dL (325 µmol/L) for discharge from the hospital. When teaching the parents about home phototherapy, which instruction should the nurse include in the discharge teaching plan? Total Bilirubin Reference Range: Newborn: 0.1 to 10.5 mg/dL (1.7 to 180 µmol/L)
      A)Feed the infant every 4 hours.
      B)Perform diaper changes under the light.
      C)Reposition the infant every 2 hours.
      D)Cover with a receiving blanket.
    4. The nurse is educating a client about essential hypertension prevention. Which information should the nurse provide? (Select all that apply.)(SATA)
      A)Alcohol consumption will not produce vascular changes.
      B)Weight management is promoted by taking daily walks for thirty minutes.
      C)Salt substitutes can help with maintaining a healthy diet.
      D)Blood pressure readings should be taken at noontime.
      E)Sodium intake can be regulated by limiting canned foods in the diet.
      F)Uncontrolled hypertension can lead to renal damage.
    Page 6 of 30