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    Exam Review

    1. A nurse is assisting with the care of client in a clinic. Based on the information in the client's medical record, which of the following findings require immediate follow-up? Select the 4 findings that require immediate follow-up by the nurse.(SATA)
      A)Blood pressure 122/80 mm Hg
      B)Attends school regularly
      C)Client experiences nightmares
      D)Heart rate 99/min
      E)Startles easy during thunderstorm
      F)Friend reporting client is not themselves
      G)smoking marijuana to clear their mind
      H)Witnessing the death of their parents and sibling
    2. A nurse is assisting with the care of a client in an outpatient clinic. Complete the following sentence by using the lists of options. The nurse should prepare to administer ▾ naloxoneand▾ oxygen 10 L/min via face mask.
      Dropdown 1:
      Option 1: an additional dose of fentanyl
      Option 2: propranolol
      Option 3: acetaminophen
      Option 4: an additional dose of propofol
      Option 5: naloxone
      Dropdown 2:
      Option 1: an additional dose of fentanyl
      Option 2: propranolol
      Option 3: acetaminophen
      Option 4: an additional dose of propofol
      Option 5: oxygen 10 L/min via face mask
    3. A home care nurse is assisting with the care of a client. The nurse is planning to focus data collection based on the general findings. Select 5 complications the client is at risk for.(SATA)
      A)Hypocalcemia
      B)Atelectasis
      C)Hypertension
      D)Urinary stasis
      E)Pressure ulcer
      F)Diarrhea
      G)Contractures
      H)calcium resorption
    4. A nurse is assisting in the care of a client receiving IV fluids. The nurse identifies that the IV pump has been infusing the fluids at double the rate of the prescribed order. After stopping the infusion, which of the following actions is the nurse's priority?
      A)Collect data on the client.
      B)Notify the provider.
      C)Notify the unit manager.
      D)Complete an incident report.
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    Exam Review

    1. A nurse is assisting with the care of a client who is in active labor. For each nursing intervention, click to specify if the intervention is essential or contraindicated for the client.
      EssentialContraindicated
      Monitor fetal heart rate.✓
      Place the client in left lateral position.✓
      Decrease the IV flow rate.✓
      Request a prescription for ephedrine.✓
      Assist with administration of ampicillin IV.✓
    2. A nurse is contributing to the plan of care for a client who has dysphagia. Which of the following interventions should the nurse include?
      A)Elevate the head of the client's bed to 30".
      B)Provide three large meals per day.
      C)Tilt the client's head forward during meals.
      D)Encourage socialization during meal times.
    3. A nurse is administering hydromorphone to a client who is experiencing postoperative pain. Which of the following findings is an adverse effect of this medication?
      A)Tachypnea
      B)Dilated pupils
      C)Urinary retention
      D)Hypertension
    4. A nurse is reinforcing teaching with a client who is undergoing radiation therapy to the neck. Which of the following instructions should the nurse include in the teaching?
      A)Eat three large meals each day.
      B)Limit fluid intake to 750 mL per day.
      C)Cleanse the neck by rubbing with a washcloth.
      D)Avoid exposing the neck to the cold.
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    Exam Review

    1. A nurse is reinforcing teaching with a newly licensed nurse about isolation precautions when caring for a client who has a Clostridioides difficile infection. Which of the following information should the nurse include in the teaching?
      A)Place dedicated equipment in the client's room.
      B)Use an alcohol-based hand rub after caring for the client.
      C)Place the client in a room with negative air pressure.
      D)Wear an N95 mask when in the client's room.
    2. A nurse is assisting with the care of a client. Select the 3 findings that require immediate follow-up.(SATA)
      A)Pedal pulses
      B)Respiratory rate
      C)Breath sounds
      D)Oxygen saturation
      E)Abdominal dressing
      F)Heart rate
    3. A nurse is assisting with the care of a client who is receiving chemotherapy and radiation for advanced breast cancer. The client states, "I am thinking about stopping the treatments." Which of the following responses should the nurse make?
      A)"I would feel the same way if I were you."
      B)"Why do you think that would be a good choice?"
      C)"Tell me more about what you are thinking."
      D)"You'll be cancer-free after you complete your treatments."
    4. A nurse is reinforcing teaching with a client who has a new prescription for enoxaparin. The nurse should identify which of the following over-the- counter products as unsafe for use with enoxaparin?
      A)Garlic
      B)Docusate
      C)Cimetidine
      D)Calcium supplement
    Page 3 of 40

    Exam Review

    1. A nurse on a unit is assisting with the care of a group of clients. Which of the following observations by the nurse requires intervention?
      A)A nursing colleague printing material that does not obtain identifiable information from a client's electronic medical record (EMR) for professional use.
      B)A nursing colleague discussing a client's diagnosis with another staff member on the unit who is not involved in the client's care.
      C)A nursing colleague documenting vitals in the electronic medical record (EMR) of a client that the colleague is caring for.
      D)A nursing colleague discussing a client's treatment plan with another nurse on the unit as part of the end-of-shift handoff report.
    2. A nurse is collecting data from a client who has macular degeneration. Which of the following findings should the nurse expect?
      A)Loss of central vision
      B)Nystagmus
      C)Client reports sharp pain
      D)Astigmatism
    3. A nurse is discussing communicable diseases with a newly licensed nurse. Which of the following statements should the nurse include?
      A)"Initiate contact precautions for a child who has measles."
      B)"Varicella is contagious until all lesions have crusted over."
      C)"Pertussis is most contagious during the paroxysmal stage."
      D)"Wear an N95 respirator mask when caring for a child who has scarlet fever."
    4. A nurse is reinforcing teaching with a newly licensed nurse about transcribing medication prescriptions. Which of the following prescriptions should the newly licensed nurse identify is an accurate transcription?
      A)Lorazepam 0.5 mg PO PRN at bedtime
      B)Doxazosin .5 mg PO at bedtime
      C)Heparin 5000 U subcutaneous every 8 hr
      D)MgSO4 10 g PO daily
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    Exam Review

    1. A nurse is providing postmortem care to a client who just died. Which of the following actions should the nurse take?
      A)Remove the client's dentures from their mouth before rigor mortis begins.
      B)Position the client's bed flat without a pillow under their head.
      C)Turn on all the lights in the room before the family views the client's body.
      D)Ask the client's family about cultural or religious practices regarding postmortem care.
    2. A nurse is collecting data from a client who has hypercalcemia. Which of the following findings should the nurse expect?
      A)Positive Trousseau's sign
      B)Increased thirst
      C)Bone fractures
      D)Muscle spasms
    3. A nurse is giving a report to their supervisor. Which of the following indicates a need for client care to be transferred to a registered nurse?
      A)The client needs routine wound care performed.
      B)The client develops a postoperative fever.
      C)The client is experiencing a therapeutic effect from their treatment.
      D)The client needs strict measurement of intake and output.
    4. A nurse is preparing to administer dextrose 5% in 0.45% sodium chloride 500 mL IV to infuse over 4 hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should adjust the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
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    Exam Review

    1. A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?
      A)Place the client in a supine position.
      B)Clamp the chest tube every 4 hr.
      C)Ensure the device is kept below the level of the client's chest.
      D)Empty the collection chamber every 8 hr.
    2. A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?
      A)Facial erythema
      B)Productive cough with thick mucous
      C)Koplik spots
      D)Beefy, red tongue
    3. A nurse is collecting data from a client who is taking an oral contraceptive. Which of the following findings is a contraindication for the use of oral contraceptives?
      A)Headaches with aura
      B)Irregular menstrual cycles
      C)History of mononucleosis 1 year ago
      D)Gastroesophageal reflux disease
    4. A nurse is assisting in the care of a client who is prescribed wound irrigation after abdominal surgery. Which of the following should the nurse identify as proper technique?
      A)Fill a 20 mL syringe with irrigation solution.
      B)Hold the syringe 7.5 cm (3 in) above the wound.
      C)Allow solution to flow from the least to the most contaminated area.
      D)Use fast and continuous pressure when flushing the wound.
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