Exam Review

A nurse is monitoring a client receiving a blood transfusion. Which of the following actions should the nurse take first?
A)Stop the blood transfusion.
B)Administer an antipyretic.
C)Encourage oral fluids.
D)Apply supplemental oxygen.
E)Send blood for type and crossmatch.
A nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?
A)Advance from clear liquids as tolerated.
B)Cefazolin 1 gram IV every 6 hours.
C)Straight catheterization if unable to void.
D)Complete blood cell count (CBC) in the morning.
After the nurse witnesses a preoperative client signing the surgical consent form, the nurse signs the form as a witness. Which is the legal implication of the nurse's signature on the client's surgical consent form? Select all that apply.(SATA)
A)Verifies that the client understands the procedure that is being performed.
B)The client is competent to sign the consent without impairment of judgment.
C)The client voluntarily grants permission for the procedure to be done.
D)The surgeon has explained to the client why the surgery is necessary.
E)The client understands the risks and benefits associated with the procedure.
The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?
A)A client with a positive Mantoux and sputum cultures results positive for acid-fast bacillus (AFB).
B)A female adolescent admitted with multiple genital herpes simplex II lesions.
C)Twin siblings admitted with scarlet fever that is complicated with pneumonia.
D)An older client with scabies who is admitted from an extended care facility.

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Exam Review

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?
A)Assess the serum potassium level every 4 hours.
B)Evaluate glucose levels before and after meals.
C)Monitor and document strict intake and output.
D)Obtain a 12-lead electrocardiogram daily.
An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)
A)Note date and time of the behavior.1
B)Evaluate the UAP for signs of improvement.3
C)Plan for scheduled break times.2
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)Brain damage with CP is not progressive but does have a variable course.
C)It is one of the most common permanent physical disabilities in children.
D)Continued development of the brain lesion determines the child's outcome.
A client expresses concern about receiving proper care in accordance with the client's religion. Which action is best for the nurse to take?
A)Consult with a nurse who shares the same religious beliefs.
B)Research the religion on different social media platforms.
C)Ask the client about individual care preferences.
D)Explain that every client will receive the same high level of care.

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Exam Review

The healthcare provider (HCP) prescribes 0.99% normal saline 500 mL IV bolus to be infused over 30 minutes. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only) .
The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?
A)Participation of community leaders in planning the program.
B)Morbidity data for breast cancer in women of all races.
C)A listing of African-American women who live in the community.
D)Technical assistance to produce a video on breast self-examination.
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)Withhold this dose.
B)Administer a half dose now.
C)Give another dose.
D)Mix the next dose with food.
A client who received an open reduction and internal fixation (ORIF) of the right femur after experiencing a fall at home experiences a sudden onset of increasing confusion and agitation. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?
A)Client's healthcare power of attorney.
B)Fall at home as reason for admission.
C)Currently prescribed medications.
D)Increasing confusion of the client.

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Exam Review

A client sustained a head injury when hit by a lead pipe two hours ago and is admitted for observation after the computerized tomography (CT) scan indicates that no spinal cord injury and no skull fractures are present. When the client begins projectile vomiting, the nurse quickly turns the client's head to the side and administers ondansetron 4 mg IV as prescribed. Reassessment indicates that the client's Glasgow coma score is 13 and the left pupil is dilated without reaction to light. Which intervention(s) should the nurse implement? Select all that apply.(SATA)
A)Place in lateral Trendelenburg position.
B)Schedule a repeat CT scan.
C)Insert a second large bore IV catheter.
D)Apply artificial tear drops to the left eye.
E)Repeat Glasgow coma assessment.
The nurse observes an unlicensed assistive personnel (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?
A)Lathering using a circular movement.
B)Turning the water off using bare hands.
C)Washing for a total of 20 seconds.
D)Holding hands below elbows when rinsing.
E)Holding hands below elbows when rinsing.
The psychiatric nurse is talking to a newly admitted client when another male client, who is diagnosed with antisocial behavior, intrudes on the conversation and tells the nurse, "I have to talk to you right now! It is very important!" How should the nurse respond to this client?
A)Inform him that the nurse is busy admitting a new client and will talk to him later.
B)Put his behavior on extinction (do not acknowledge it) and continue talking with the newly admitted client.
C)Introduce him to the newly admitted client and ask him to join in the conversation.
D)Encourage him to go to the nurse's station and talk with another nurse.
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)Check for pedal edema.
B)Measure body temperature.
C)Observe the color of urine.
D)Assess skin turgor.

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Exam Review

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?
A)Don an N95 respirator mask, face shield, gown, gloves, and shoe coverings prior to returning to the room.
B)Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.
C)Explain to the client to inform others that they may have been potentially exposed in the last 14 days.
D)Notify the charge nurse that the client will need assignment to the COVID-19 specified area of the facility.
The nurse is providing a nutrition class to a group of postmenopausal clients. Which food should the nurse emphasize to this group?
A)Mixed berries.
B)Low-fat yogurt.
C)Carrots.
D)Beets.
The nurse is preparing to administer a formula feeding by nasogastric tube (NGT) to a 2-month-old. Which intervention should the nurse implement?
A)Measure and discard residual gastric contents before feeding.
B)Use the syringe plunger to push formula at a rate of 5 mL per minute.
C)Hold the infant with head and shoulders slightly elevated.
D)Microwave refrigerated formula to room temperature.
A client who was a victim of a rape and was confirmed HIV positive six months ago arrives at the clinic for an appointment. The client is thin, with a saddened affect and talks about frequently crying and feeling hopeless. The client describes not wanting to see anyone or go out of the house. Which action should the nurse take?
A)Explain the ELISA test will be needed to confirm the results.
B)Identify support systems in the client's life.
C)Inquire about plans to further education.
D)Explore feelings of hope for the future.
E)Inquire about plans to further education.

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Exam Review

The nurse is providing education to a client who receives a prescription for zolpidem. Which information about the medication should the nurse include?
A)Crush to increase absorption.
B)Take before bedtime.
C)Administer with a meal.
D)Store at room temperature.
The nurse is managing the care for a client with hyperparathyroidism and is reviewing the client's list of prescribed and over-the-counter medications. Which medication(s) on the client's current medication record should the nurse discuss further with the healthcare provider? Select all that apply.(SATA)
A)Calcium carbonate.
B)Acetaminophen.
C)Hydrochlorothiazide.
D)Lithium carbonate.
The nurse is completing the admission assessment of a client with multiple sclerosis (MS). Which finding(s) should be reported to the healthcare provider immediately? Select all that apply.(SATA)
A)Paresthesia.
B)Tremors.
C)Tinnitus.
D)Fever.
E)Tachycardia.
The friend of a nurse who works in an acute care hospital asks the nurse to review the adult daughter's electronic medical record (EMR) to determine if she is honestly disclosing her medical condition. The nurse's reply should include which information? Select all that apply.(SATA)
A)EMR safeguards prohibit access to medical records for personnel not involved in direct care of the client.
B)The daughter's permission needs to be obtained before the information can be shared by the nurse.
C)Encourage the friend to share her concerns with her daughter and other family members.
D)Review of the EMR violates client confidentiality and is not permitted legally or ethically.
E)EMR tracking alerts the hospital information systems of the nurse's attempts to access the record.

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