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    Exam Review

    1. The physician orders Ancef 500 mg IV for a urinary tract infection. After reconstitution, the medication is available as 330 mg/mL. How many milliliters will the nurse administer?
    2. The nurse is caring for a client who has a bowel obstruction and a new prescription for the insertion of a nasogastric tube.Which of the following interventions should the nurse take when inserting the nasogastric tube?
      A)Place the client in a prone position.
      B)Measure the tube for insertion from the tip of the nose to the earlobe to the xiphoid process.
      C)Instruct the client to place their chin to their chest and swallow.
      D)Advance the tube quickly to minimize discomfort.
    3. A clinical instructor is reviewing the abdominal assessment with a group of students.She would include which of the following three percussion sounds the nurse would expect to hear? (Select 3 options)(SATA)
      A)Hyperresonance.
      B)Flatness.
      C)Dullness.
      D)Resonance.
      E)Tympany.
    4. The nurse is preparing to examine a patient who has been reporting right lower quadrant (RLQ) pain.Which technique is correct during the assessment?
      A)Palpate the tender area first and then auscultate for bowel sounds.
      B)Examine the tender area last.
      C)Examine the tender area first.
      D)Avoid palpating the tender area altogether.
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    Exam Review

    1. A nurse inspects the abdomen for skin color, contour, surface characteristics, and symmetry.What part of the abdominal assessment does the nurse perform next?
      A)Light palpation for tenderness and muscle tone.
      B)Auscultation of the bowel sounds in all four quadrants.
      C)Percussion for tones in all four quadrants.
      D)Deep palpation for masses or aortic pulsations.
    2. A nurse is planning care for a client who has dysphagia.The nurse should plan to assist with the request of a referral to which of the following members of the health care team?
      A)Speech therapist.
      B)Respiratory therapist.
      C)Dentist.
      D)Physical therapist.
    3. The nurse places a nasogastric tube (NGT) as ordered by the physician.When confirming placement, the nurse aspirates stomach contents and measures the gastric pH at 3. What should the nurse do next?
      A)Secure the tube and retest the pH in one hour.
      B)Insert the tube an additional 1-2 inches and retest the pH.
      C)Auscultate for the "swoosh" of air.
      D)Obtain an x-ray to confirm placement.
    4. A nurse is caring for a client who has dysphagia.Which of the following actions should the nurse take?
      A)Instruct the client to tilt their head back while swallowing.
      B)Elevate the client's head of the bed to 45° during meals.
      C)Alternate the client's liquids and solids during meals.
      D)Encourage the client to lie flat after meals.
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    Exam Review

    1. The physician orders Salagen 10 mg PO twice a day for dry eyes. The medication is supplied in 5-mg tablets. How many tablets will the nurse administer?
    2. A nurse is reinforcing teaching with an older adult client who is on bed rest about foods high in dietary fiber.Which of the following food items should the nurse indicate is the best source of fiber?
      A)Canned pineapple.
      B)Mashed potatoes.
      C)Celery.
      D)Pears with skin.
    3. A nurse is preparing to administer an enteral feeding via an established NG tube. Identify the sequence the nurse should follow to initiate the feeding. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
      A)Verify tube placement.1
      B)Check the residual feeding contents.2
      C)Administer the feeding.3
      D)Evaluate tolerance to the feeding.4
    4. A patient states during the interview that she noticed a new lump in the shower a few days ago.It was on her left breast near her axilla.How should the nurse proceed?
      A)Palpated the unaffected breast first.
      B)Palpate the breast with the lump first, but plan to palpate the axilla last.
      C)Avoid palpating the lump because it could be a cyst, which might rupture.
      D)Palpate the lump first.
    Page 3 of 14

    Exam Review

    1. Chelsea Green is a 16-year-old white young woman brought to the health clinic today by her mother, Lisa Green.Chelsea is a sophomore high school student who appears extremely underweight.Lisa has been concerned for a while and decided that she needs to be seen by a health care professional.Chelsea is not pleased to be at the appointment but agreed to come.Rachael is a 30-year-old student nurse assigned to Sylvia, who is the nurse practitioner at the clinic.They go in to see Chelsea.Mrs.Green tells them that Chelsea has been eating only small amounts and then works out 3 to 4 hours each day.Chelsea tells them that she does not want to get fat like her mother.On assessment, Chelsea's body mass index is 17. Lisa Green asks Rachael if she can recommend a healthy diet for her as well.She tells Rachael that she has gained 20 lb in the past few years and is overweight as Chelsea pointed out.To what resource sponsored by the USDA could Rachael refer Mrs.Green?
      A)Nutrisystems.
      B)MyPlate.
      C)Weight Watchers.
      D)eDiets.com.
    2. A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke.Which of the following actions should the nurse take?(SATA)
      A)Add thickener to fluids.
      B)Place food on the right side of the client's mouth.
      C)Serve food at a very hot temperature.
      D)Instruct the client to tilt her head forward when she swallows.
    3. The MD orders a pre-op patient to have Kefzol 1g to be infused over 15 minutes. The Kefzol is diluted in 50 mL of D5W. How many milliliters per hour will the nurse infuse the drug?
    4. When assessing a 49-year-old woman who has a nursing diagnosis of imbalanced nutrition, less than body requirements related to dysphagia, which data would the nurse expect to find?
      A)Increased hair growth.
      B)Sore, inflamed buccal cavity.
      C)Adequate nutrient or food intake.
      D)Weight within 10% of ideal body weight.
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    Exam Review

    1. A patient has been blind for several years because of complications with diabetes mellitus.Which should the nurse do to assist this patient with meals?
      A)Explain to the patient where items are located on the plate according to the hours on a clock.
      B)Encourage eating one food at a time according to the preferences of the patient.
      C)Order finger foods that are permitted on the patient's diet.
      D)Feed the patient the prescribed meal.
    2. The nurse, upon reviewing the history, discovers the patient has dysphagia.Which assessment finding is consistent with dysphagia?
      A)Trouble chewing foods such as meats and raw vegetables.
      B)Awakenings with a feeling of indigestion.
      C)Feeling of choking after swallowing.
      D)Frequent burping.
    3. A client with a nasogastric tube has an order for the tube to be removed.As the nurse removes the tube, the client should be asked to:
      A)Breathe in and out normally.
      B)Take a deep breath and cough.
      C)Hold her breath.
      D)Bear down like having a bowel movement.
    4. A nurse is collecting data from a client who has an inadequate dietary intake of fiber.Which of the following findings should the nurse expect?
      A)Memory loss.
      B)Bleeding gums.
      C)Brittle hair.
      D)Constipation.
    Page 5 of 14

    Exam Review

    1. A 65-year-old patient remarks that she just can't believe that her breasts "sag so much.”. She states it must be from a lack of exercise.What explanation would the nurse offer her?
      A)After menopause, the glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breasts that sag.
      B)After menopause, a diet that is high in protein will help maintain muscle mass, which keeps the breasts from sagging.
      C)After menopause, sagging is usually due to decreased muscle mass within the breast.
      D)After menopause, only women with large breasts experience sagging.
    2. The nurse is caring for a young woman who is breastfeeding and will need to increase her intake of calories and protein.The nurse suggests which foods are healthy sources of protein?
      A)Green leafy vegetables.
      B)Citrus fruits and juices.
      C)White bread, rice, and potatoes.
      D)Nuts, turkey breast, and lean meats.
    3. The nurse is assessing a patient's bowel sounds.The nurse does not hear anything for 30 seconds.How should the nurse document this finding?
      A)Normoactive bowel sounds.
      B)Hypoactive bowel sounds.
      C)Absent bowel sounds.
      D)Hyperactive bowel sounds.
    4. During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast.Which of these statements is true about this finding?
      A)Asymmetry of breast size and shape is very unusual and means she may have an inflammation or growth.
      B)Asymmetry of the breasts is common, but the nurse should verify that this finding is not new.
      C)Asymmetry of the breast is unusual, and the patient should be referred to a physician.
      D)Asymmetry of breast size and shape is probably due to breastfeeding and is nothing to worry about.
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