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    Exam Review

    1. A client who is one day postpartum reports to the nurse that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?
      A)Offer supplemental formula feedings.
      B)Teach about the use of a breast pump.
      C)Recommend using a breast shield.
      D)Encourage the use of ice on the areola.
    2. A client who is one day postpartum reports that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?
      A)Offer supplemental formula feedings.
      B)Teach about the use of a breast pump.
      C)Recommend using a breast shield.
      D)Encourage the use of ice on the areola.
    3. A nurse is caring for a client who underwent an appendectomy 2 days ago and now reports sudden, unbearable pain in the left great toe. The client has a medical history of type 2 diabetes mellitus, gouty arthritis, and gastroesophageal reflux disease (GERD). Which instruction should the nurse include in the discharge teaching?
      A)Eat high-protein foods to achieve ideal body weight.
      B)Avoid acetylsalicylic acid-containing medications.
      C)Wrap joints with an elastic bandage when swollen.
      D)Support joints in an extended position while resting.
    4. A client with cirrhosis of the liver reports a 5 lb (2.3 kg) weight gain within the last week during a physical assessment. Which assessment finding correlates with the client's report?
      A)Decreased bowel sounds.
      B)Increased respiratory rate.
      C)Increased abdominal girth.
      D)Decreased level of consciousness.
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    Exam Review

    1. The healthcare provider prescribes a placebo instead of pain medication. Which intervention should the nurse implement?
      A)Tell the charge nurse about the prescribed placebo and refuse to administer it.
      B)Discuss ethical concerns about placebo use with the healthcare provider.
      C)Administer the placebo as prescribed when the client reports pain.
      D)Inform the client that the provider prescribed a placebo instead of pain medication.
    2. The healthcare provider prescribes ear drops to an adult client with an ear infection. Which teaching should the nurse provide?
      A)Cool and shake the bottle before administering the drops.
      B)Insert the tip of the dropper into the canal of the ear.
      C)Pull the pinna up and back to administer the drops.
      D)Administer the drops with the head held upright.
    3. A client with type 1 diabetes mellitus (DM) is admitted in diabetic ketoacidosis. Treatment is initiated, and the nurse is preparing to administer IV fluids containing potassium chloride. Which assessment data is most important for the nurse to obtain before starting the infusion?
      A)Urinary output of 30 to 60 mL/hr.
      B)Magnesium level.
      C)Size of the IV catheter.
      D)Serum glucose level.
    4. An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?
      A)Encourage the client to lie as still as possible during the assessment.
      B)Ask the client how often episodes of sundowning are experienced.
      C)Assist the client with values clarification about end-of-life care options.
      D)Question the client about the frequency of falls in recent months.
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    Exam Review

    1. Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's plan of care?
      A)Measure body temperature.
      B)Assess skin turgor.
      C)Check for pedal edema.
      D)Observe the color of urine.
    2. The nurse is caring for an older adult client with a history of osteoarthritis who is having difficulty walking due to increased right knee pain. To assess the quality of the client's knee pain, which approach should the nurse use?
      A)Ask the client to describe the pain.
      B)Observe body language and movement.
      C)Identify effective pain relief measures.
      D)Provide a numeric pain scale.
    3. The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. What instruction(s) should the nurse include in the client's discharge teaching plan? Select all that apply.(SATA)
      A)Avoid prolonged standing or sitting.
      B)Cross legs at the knee but not at the ankle.
      C)Continue wearing compression stockings.
      D)Use a recliner for long periods of sitting.
      E)Maintain the bed flat while sleeping.
    4. A client with osteomyelitis from a compound fracture of the left tibia has an open draining wound and is admitted with a possible methicillin-resistant Staphylococcus aureus (MRSA) infection. What intervention(s) should the nurse include in the plan of care? Select all that apply.(SATA)
      A)Use standard precautions and wear a mask.
      B)Explain the purpose of a low bacteria diet.
      C)Institute contact precautions for staff and visitors.
      D)Send wound drainage for culture and sensitivity.
      E)Monitor the client's white blood cell count.
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    Exam Review

    1. The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning?
      A)An 8-year-old who lives in a housing project.
      B)A 2-year-old who plays on aging outdoor playground equipment.
      C)An adolescent who works part-time in a paint factory.
      D)A 10-year-old who has Type 1 diabetes mellitus.
    2. Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?
      A)Move the client to a private room, keep the door closed, and initiate droplet precautions.
      B)Place the nasal swab specimen for COVID-19 directly into a biohazard bag.
      C)Assist the client to recall everyone possibly exposed since the onset of symptoms.
      D)Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.
    3. An older adult client with a history of heart failure is admitted to the medical unit after falling at home and has become increasingly confused. The client's spouse is designated as the client's power of attorney. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?
      A)Fall at home as the reason for admission.
      B)Increasing confusion of the client.
      C)Client's healthcare power of attorney.
      D)Currently prescribed medications.
    4. One hour after arriving on the postoperative unit, a woman who received spinal anesthesia 5 hours ago is complaining of severe abdominal incisional pain. Her vital signs include oral temperature 99.0°F (37.2°C), heart rate 110 beats/minute, respiratory rate 30 breaths/minute, and blood pressure 160/90 mm Hg. The client's skin is pale, and the surgical dressing is dry and intact. Which intervention is most important for the nurse to implement?
      A)Administer an IV analgesic.
      B)Assess the IV site for patency.
      C)Provide a pillow for splinting.
      D)Place in a high-Fowler's position.
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    Exam Review

    1. What conditions are most likely to respond to treatment with antihistamines? Select all that apply.(SATA)
      A)Allergic rhinitis.
      B)Otitis media.
      C)Myocarditis.
      D)Bronchitis.
      E)Contact dermatitis.
    2. A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a "Do Not Resuscitate" prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously scheduled. Which action should the nurse take?
      A)Advise the UAP to resume positioning the client on schedule.
      B)Encourage the UAP to provide comfort care measures only.
      C)Assume total care of the client to monitor neurologic function.
      D)Assign a practical nurse to assist the UAP in turning the client.
    3. An older adult client arrives at the clinic describing a new onset of urinary incontinence. Which intervention should the nurse implement?
      A)Obtain a clean, voided urine specimen for analysis.
      B)Evaluate the client's response to bladder training efforts.
      C)Provide protective undergarments for the client.
      D)Encourage increased fluid intake for 24 hours.
    4. The nurse notes that a client with depression has been more withdrawn and noncommunicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?
      A)Engage the client in non-threatening conversations.
      B)Encourage the client's family to visit more often.
      C)Schedule a daily conference with the social worker.
      D)Encourage the client to participate in group activities.
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    Exam Review

    1. The nurse administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, what laboratory values should the nurse monitor? Select all that apply.(SATA)
      A)White blood cell (WBC) count.
      B)Red blood cell (RBC) count.
      C)Serum potassium.
      D)Blood urea nitrogen (BUN).
      E)Sputum culture and sensitivity.
      F)Urinalysis.
    2. A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. Which action should the nurse take first?
      A)Activate the lockdown procedure.
      B)Match ID bands of all infants and mothers on the unit.
      C)Ask the mother if any visitors were expected to arrive.
      D)Determine if the newborn is in the nursery.
    3. The healthcare provider prescribes a 5% dextrose injection with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care? Reference Range: Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)] Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]
      A)Obtain a 12-lead electrocardiogram daily.
      B)Evaluate glucose levels before and after meals.
      C)Monitor and document strict intake and output.
      D)Assess the serum potassium level every 4 hours.
    4. Twenty minutes after the onset of symptoms, an adult client presents to the emergency department with slurred speech and right-sided weakness. After a computerized tomography (CT) scan reveals a non-hemorrhagic stroke, the nurse administers alteplase. Which assessment finding warrants immediate intervention?
      A)Headache with blurred vision.
      B)Lower extremity edema.
      C)Paroxysmal supraventricular tachycardia.
      D)Frequent premature ventricular contractions.
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