NursingPlex
    Sign In
    Review ModeExam ModePractice Mode

    Exam Review

    1. The parent of a 4-year-old has been battling metastatic lung cancer for the past 2 years. After discussing the remaining options with the healthcare provider, the client requests that all treatment stop and that no heroic measures be taken to save the client's life. After the client is transferred to the palliative care unit, which action is most important for the receiving nurse to take in facilitating continuity of care?
      A)Mark the chart with client's request for no heroic measures.
      B)Reassure the client that the client's child will be allowed to visit.
      C)Provide the client written information about end-of-life care.
      D)Obtain a detailed report from the nurse transferring the client.
    2. In caring for a client following a head injury, the nurse plans to assess for rhinorrhea so that a sample can be tested for the presence of cerebrospinal fluid (CSF). At which location should the nurse observe for this finding? (Click the chosen location. To change, click on the new location.)
      Correct Answer:"{\"xRanges\":[66.94915254237287,72.59887005649716],\"yRanges\":[83.8235294117647,98.52941176470588]}"
    3. A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?
      A)Place an indwelling urinary catheter and institute strict intake and output measurements.
      B)Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema.
      C)Administer four 81 mg aspirin tablets providing instructions to chew before swallowing.
      D)Secure client consent for coronary angiography and percutaneous coronary intervention.
    4. A client is admitted to the intensive care until (ICU) with a spinal cord injury following a motor vehicle collision. Which nurse should be contacted to coordinate the progression of the client's care?
      A)Nurse case manager.
      B)Neurology unit supervisor.
      C)Risk management nurse.
      D)Adult nurse practitioner.
    Page 1 of 32

    Exam Review

    1. 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)Encourage him to go to the nurse's station and talk with another nurse.
      C)Introduce him to the newly admitted client and ask him to join in the conversation.
      D)Put his behavior on extinction (do not acknowledge it) and continue talking with the newly admitted client.
    2. 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 the client will need assignment to the COVID-19 specified area of the facility.
    3. A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instruction(s) should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Select all that apply.(SATA)
      A)Determine if the client needs to have a gait belt applied.
      B)Offer to assist the client to void prior to walking in the hall.
      C)Instruct the client about signs of orthostatic hypotension.
      D)Report the onset of any dizziness or light headedness.
      E)Measure the client's vital signs before the client walks.
    4. 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)Feelings of disorientation.
      B)Undiagnosed social anxiety symptoms (SAD).
      C)History of suicide attempts.
      D)Family history of schizophrenia.
    Page 2 of 32

    Exam Review

    1. 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.
    2. The nurse assesses a client who had bilateral total knee replacements (TKR) four hours ago. The nurse notes that the dressing on the client's right knee is saturated with serosanguineous drainage. Which action should the nurse implement?
      A)Monitor the client's current white blood cell count (WBC).
      B)Determine if the wound drainage device is functioning correctly.
      C)Withhold next scheduled dose of low molecular weight heparin.
      D)Confirm that the continuous passive motion device is intact.
    3. A client who weighs 22 pounds receives a prescription for amoxicillin 50 mg/kg/day PO in divided doses every 8 hours. The bottle is label "Amoxicillin for Oral Suspension, USP 250 mg per 5 mL". How many mL should the nurse administer with each dose? (Enter numerical value only. If rounding is required, round to the nearest tenth.)
    4. Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. Which action should the nurse take?
      A)Administer an antiemetic to prevent vomiting.
      B)Apply bilateral eye shields to reduce photosensitivity.
      C)Begin postoperative prophylactic antibiotics.
      D)Report the eye pain to the surgeon.
    Page 3 of 32

    Exam Review

    1. The nurse is caring for a client who reports running out of aspirin 1 week ago and taking ibuprofen as a replacement. Which information should the nurse obtain from the client first?
      A)Amount of pain control.
      B)Dosage of ibuprofen taken.
      C)Presence of gastric pain.
      D)Reason for taking the aspirin.
    2. A client who was a victim of a rape and was confirmed HIV positive six months ago arrives to 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)Identify support systems in the client's life.
      B)Explain the ELISA test will be needed to confirm the results.
      C)Inquire about plans to further education.
      D)Explore feelings of hope for the future.
    3. 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)Collect a serum sample for hemoglobin and hematocrit.
      B)Obtain clean catch urine for culture and sensitivity.
      C)Give diphenhydramine prep for intravenous pyelogram.
      D)Force oral fluids to 2,000 mL/24 hours.
      E)Initiate broad spectrum IV antibiotic as secondary infusion.
    4. Exhibits Choose the most likely options missing from the statements by selecting from the list of options provided. The nurse teaches the client about the fetus reactions to labor by ▾ Describing heart rate patterns . The nurse will assess the fetus  reaction by ▾ Continuous fetal monitoring.
      Dropdown 1:
      Option 1: Describing contractions
      Option 2: Describing heart rate patterns
      Option 3: Assessing mothers vital signs
      Option 4: Performing vaginal examination
      Option 5: Continuous fetal monitoring
      Dropdown 2:
      Option 1: Describing contractions
      Option 2: Describing heart rate patterns
      Option 3: Assessing mothers vital signs
      Option 4: Performing vaginal examination
      Option 5: Continuous fetal monitoring
    Page 4 of 32

    Exam Review

    1. A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair. Which intervention is most important for the nurse to include in the plan of care?
      A)Record the amount of daily wound drainage.
      B)Replace fluids IV based on intake and output.
      C)Assess skin condition and turgor for breakdown.
      D)Turn every 2 hours around the clock from side-to-side.
    2. 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 older adult who is scheduled for foot amputation due to diabetes complications.
      B)An adult with alcoholism, cirrhosis, and hepatic encephalopathy.
      C)An adult who is one day postoperative for a laparoscopic cholecystectomy.
      D)An older client who is one day postoperative with a colostomy for colon cancer.
    3. When providing client care, the nurse identifies a problem and develops a related clinical question. Next, the nurse intends to gather evidence so that the decision-making process in response to the problem and clinical question is evidence-based. When gathering evidence, which consideration is most important?
      A)Relevance to the situation.
      B)Frequency that the problem occurs.
      C)Past experience with similar problems.
      D)Related personal values.
    4. The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?
      A)Complete ongoing focused assessments of a client with wrist restraints.
      B)Supervise a newly hired graduate nurse during an admission assessment.
      C)Administer PRN oral analgesics to a client with a history of chronic pain.
      D)Transport a client who is receiving IV fluids to the radiology department.
    Page 5 of 32

    Exam Review

    1. 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 will express acceptance of his changing health status.
      B)The client's family will state signs and symptoms about the disease.
      C)The client's daily blood pressure will be less than 140/80 mm Hg this month.
      D)The nurse will demonstrate the procedure for accurate eye care.
    2. After removing a client's dressing that is saturated with sanguineous drainage, where should the nurse place the dressing?
    3. When changing the client's dressing for a vacuum-assisted closure (VAC) wound therapy system, the nurse observes foul, purulent drainage. Which intervention(s) should the nurse implement? Select all that apply.(SATA)
      A)Increase the wound VAC suction to eliminate the drainage.
      B)Document the wound measurements with tunneling.
      C)Consult the wound care specialist to evaluate the wound.
      D)Reapply the VAC system after irrigating away drainage.
      E)Cleanse the wound and discontinue the VAC system.
    4. Exhibits select from Word Choices to complete the sentence. The client receiving epidural anesthesia would be at risk for developing ▾ Hypotension due to ▾ Peripheral vasodilation
      Dropdown 1:
      Option 1: Inadequate pain relief
      Option 2: Hypotension
      Option 3: Fluid overload
      Option 4: Urinary retention
      Dropdown 2:
      Option 1: Decreased fetal heart rate
      Option 2: full urinary bladder
      Option 3: Inability to push
      Option 4: Peripheral vasodilation
    Page 6 of 32