Exam Review

A nurse is caring for a client in the emergency department (ED). Exhibits Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing 2 actions the nurse should take to address that condition and 2 parameters the nurse should monitor to assess the client's progress.
✓Prepare to initiate mechanical ventilation
✓Obtain a prescription for naloxone
✓Opioid intoxication
✓Pupillary reaction
✓Respiratory rate
Actions to Take
✕Obtain prescription for restraints
✓Prepare to initiate mechanical ventilation
✕Collect a blood sample for ethanol level
✕Anticipate administering clonidine
✓Obtain a prescription for naloxone
Potential Condition
✕Opioid withdrawal
✕Stimulant intoxication
✕Alcohol intoxication
✓Opioid intoxication
Parameters to Monitor
✓Pupillary reaction
✕Hyperreflexia
✕Cardiac arrhythmias
✕Ethanol level
✓Respiratory rate
A nurse is caring for a toddler in the outpatient setting. Exhibits Complete the following sentence by using the lists of options. The nurse recognizes the toddler has likely developed ▾ Reye syndromedue to▾ Aspirin administration.
Dropdown 1:
Option 1: Reye syndrome
Option 2: Bronchitis
Option 3: gastroenteritis
Dropdown 2:
Option 1: Oseltamivir administration
Option 2: Acetaminophen administration
Option 3: Aspirin administration

A nurse is caring for a client in the outpatient health clinic. Exhibits For each potential nursing Intervention. click to specify if the intervention is indicated or not indicated.

	Indicated	Not Indicated
Encourage high-calorie finger foods.	✓
Advise client to rise slowly from sitting position.	✓
Instruct client to avoid foods that have been fermented or aged.		✓
Encourage naps during the day when client is tired.		✓
Encourage client to sleep until later in the morning.		✓
Advise client to notify provider if pregnant.	✓
Encourage a regular sleep-wake schedule.	✓

A nurse is caring for a client who is to undergo a bilateral prophylactic mastectomy. The client states that her family opposes her decision. Which of the following responses should the nurse make?
A)“Your family disagrees with your decision?”
B)"Did you tell your provider that your family doesn't agree with your decision?"
C)“You are making the same decision I would make."
D)“You should get your family to agree with your decision before signing the consent.”

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Exam Review

A nurse is caring for a client who has an allergy to penicillin. The health care provider has prescribed amoxicillin. Which of the following actions should the nurse take?
A)Call the pharmacist for clarification of the medication contraindications.
B)Place an incident report in the medical record.
C)Discuss the prescription with the health care provider.
D)Administer the medication as prescribed.
A nurse is teaching participants at a community center about advance directives. Which of the following information should the nurse include in the teaching?
A)A health care surrogate makes health care decisions Mien the client is no longer able.
B)Advance directives cannot be changed once implemented.
C)Assigning a health care surrogate requires legal consultation.
D)A client must create a do-not-resuscitate order when completing advance directives.
A nurse is caring for a client who has cancer and is being transferred to hospice care. The client's daughter tells the nurse, "I'm not sure what to say to my morn if she asks me about dying," Which of the following responses by the nurse is appropriate? (Select all that apply.)(SATA)
A)"Tell me how you are feeling about your mom dying."
B)“Tell her not to worry. She still has plenty of time left."
C)“Hospice will take good care of your mom, so I wouldn't worry about that."
D)“You sound like you have questions about your mom dying. Let’s talk about it."
E)“Let’s talk about your mom’s cancer and how things will progress from here.”
A nurse is teaching a client who has a newly documented latex allergy. Which of the following statements by the client indicates an understanding of the teaching?
A)“I will remove dairy products from my diet."
B)“l will remove gluten from my diet.”
C)“I will remove peanuts from my diet.”
D)“I will remove bananas from my diet.”

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Exam Review

A community health nurse is performing a home visit for a client and is evaluating the home environment for safety. Which of the following findings would indicate to the nurse that the client has a proper understanding of safety in the home?
A)A single light fixture hangs along the sidewalk to the house.
B)The water heater is set at 54℃ (129.2° F).
C)A small area rug is placed at the front door.
D)The batteries in the smoke alarms are changed annually.
A nurse in an outpatient clinic is assessing a client who is pregnant for unsafe behaviors during pregnancy. Which of the following findings indicates a need for further evaluation?
A)The client is doing 30 min of moderate exercise daily.
B)The client last visited the dentist 4 months ago.
C)The client started working in a parking garage 3 months ago.
D)The client is drinking 2.5 L of water per day.
A nurse is caring for a client who has expressive aphasia. Which of the following actions should the nurse take to assist the client in overcoming communication barriers?
A)Provide educational materials with large print,
B)Use a mechanical voice amplifier.
C)Establish alternatives to verbal conversation.
D)Have the client's glasses brought from home.
A nurse is assessing a I-month-old infant at a pediatric office. Which of the following findings requires a referral for further care?
A)Femoral head remains in the acetabulum during the Barlow maneuver
B)Symmetric gluteal and thigh skin folds
C)Equal leg length
D)Limited hip abduction

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Exam Review

A nurse on a mental health unit is planning care for a client who is being admitted immediately following a sexual assault. Which of the following interventions should the nurse include in the plan of care?
A)Ask the client for details about the assault.
B)Instruct the client to shower and change their clothes.
C)Reassure the client that their injuries are not life threatening.
D)Limit the number of staff members providing care for the client.
A nurse is caring for a client who is in the emergency department with multiple traumatic injuries following a motor-vehicle crash. Which of the following actions should the nurse take first?
A)Warm blood products prior to administration.
B)Establish a patent oral airway.
C)Assign the client a score on the Glasgow Coma Scale.
D)Remove the client's clothing.
A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply.)(SATA)
A)Approach the client from the side.
B)Ensure there is high-wattage lighting in the client’s room.
C)Keep objects in the client’s room in the same place.
D)Allow extra time for the client to perform tasks.
E)Touch the client gently to announce presence.
A nurse has been assigned to an internal disaster drill team and is triaging clients. Which of the following clients should the nurse classify with a green tag?
A)A client who has an open compound fracture of the humerus
B)A client who has multiple facial lacerations
C)A client who has full-thickness burns over the lower extremities
D)A client who has a puncture wound in the right lower lung

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Exam Review

A nurse is assessing a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse that the client is at risk for developing a surgical wound infection?
A)Blood glucose 90 mg/dL (74 to 106 mg/dL)
B)White blood cell count (5, 000 to 10, 000/mm3)
C)Body mass index of 32
D)Temperature 36.8℃ (98° F)
A nurse is caring for a client who is dilated to 10 cm and pushing. Which of the following pain-management measures should the nurse identify as a safe option for the client?
A)Butorphanol tartrate
B)Naloxone hydrochloride
C)Spinal anesthesia
D)Pudendal block
A nurse is initiating bladder retraining for a client who has urge urinary incontinence. Which of the following instructions should the nurse give the client?
A)“Take your diuretic medication with your evening meal."
B)“Decrease your intake of cranberry juice.”
C)“Plan to urinate every 3 hours while you are awake."
D)“Limit your fluid intake to 500 milliliters per day."
A nurse is preparing to perform a dressing change on a preschooler. Which of the following actions should the nurse take to prepare the child for the procedure?
A)Instruct the child in deep-breathing methods prior to the procedure.
B)Explain in simple terms how the procedure will affect the child.
C)Ask the parents to wait outside the room during the procedure.
D)Limit teaching sessions about the procedure to 20 min.

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Exam Review

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?
A)Administer a dose of atomoxetine to decrease anxiety.
B)Encourage the client to watch television.
C)Teach the client how to meditate.
D)Sit with the client to provide a sense of security.
A nurse is evaluating a client who received intermittent IV fluids. Which of the following findings indicates the client has a fluid overload?
A)Tenting skin turgor
B)Respiratory rate 30/min
C)Heart rate 60/min
D)Skin warm and dry
A charge nurse is teaching newly licensed nurses about postoperative procedures following abdominal surgery. Which of the following information should the charge nurse include?
A)“Ensure the client's urinary output is no less than 20 per hour."
B)“Expect the client to have a palpable distended bladder following surgery."
C)“Report bleeding that saturates the client's dressing."
D)“Maintain the client in a supine position for 24 hours following surgery."
A nurse is reviewing home care with a client who has multiple sclerosis. Which of the following precautions should the nurse recommend to promote client safety?
A)Avoid the use of orthotics.
B)Walk with feet close together for stability.
C)Use a cane for support while walking.
D)Implement a rigorous range-of-motion exercise plan.

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