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    Exam Review

    1. The nurse is assigned a post-operative total hip replacement patient reporting incisional pain that is not managed with current pain medications. Exhibits Complete the following sentence using the drop-downs. The nurse should determine whether the IV line is ▾ Patentbecause ▾ obstructioninterferes with▾ Medication delivery.
      Dropdown 1:
      Option 1: Patent
      Option 2: Properly secured
      Option 3: Malpositioned
      Dropdown 2:
      Option 1: extravasation
      Option 2: infiltration
      Option 3: obstruction
      Option 4: phlebitis
      Dropdown 3:
      Option 1: Medication delivery
      Option 2: Fluid administration
      Option 3: Tissue damage
    2. A nurse is caring for a client in septic shock due to a wound infection. Despite aggressive fluid resuscitation, the client has a blood pressure of 78/50 and a heart rate of 136 beats per minute. The nurse contacts the provider. Which of the following orders does the nurse expect to receive from the provider?
      A)Start infusion of Nitroprusside 100mg/250mL D5W
      B)Start infusion of Dobutamine 500mg/250mL D5W
      C)Start infusion of Nitroglycerin 50mg/250mL 0.9%NS
      D)Start infusion of Norepinephrine 4mg/250mL DSW
    3. A patient tests positive for HIV. Exhibits Which statements should the nurse include in the patient's education? Select 3 responses.(SATA)
      A)These medications should keep the viral load suppressed
      B)There are no side effects of ART.
      C)Headache, nausea, vomiting, and anorexia are known side effects of these medications.
      D)We will measure the effectiveness of ART by measuring CD4+T cell counts
      E)Take ART with antiacids to ensure they do not upset the stomach
      F)ART medications will cause wasting syndrome.
      G)ART causes insomnia, so it should be taken at night
      H)If you miss a dose of medication, take two of that pill as soon as you think of it.
    4. A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
      A)Weight
      B)Urine output
      C)BP
      D)Heart rate
    Page 1 of 10

    Exam Review

    1. A nurse is caring for a client who has HIV-1 infection and is prescribed zidovudine as part of antiretroviral therapy. The nurse should monitor the client for which of the following adverse effects of this medication?
      A)Cardiac dysrhythmia
      B)Renal failure
      C)Aplastic anemia
      D)Metabolic alkalosis
    2. The nurse is caring for a patient with a new diagnosis of gastroesophageal reflux disease. The patient asks what types of food they should avoid. The nurse tells the patient to avoid which of the following foods? (Select All that Apply.)(SATA)
      A)Chocolate
      B)French fries
      C)Oatmeal
      D)Chicken
      E)Grapefruit
    3. You are caring for a patient post-op after bariatric surgery. Complete the sentence using the drop-down choices. The nurse knows that the patient needs to ambulate post-op for several reasons. This can help the patient ▾ Improve circulationas well as help prevent▾ Deep vein thrombosis (DVT).
      Dropdown 1:
      Option 1: Improve circulation
      Option 2: Reduce pain
      Option 3: Increase appetite
      Dropdown 2:
      Option 1: Deep vein thrombosis (DVT)
      Option 2: Infection
      Option 3: Pressure ulcers
      Option 4: Dehydration
    4. A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?
      A)Hypertension
      B)Flushing of the skin
      C)Oliguria
      D)Bradypnea
    Page 2 of 10

    Exam Review

    1. A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first?
      A)Furosemide
      B)Dobutamine
      C)Epinephrine
      D)Methylprednisolone
    2. A nurse is caring for a client on the medical-surgical unit. 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 insert a nasogastric tube
      ✓Make the client NPO
      ✓Paralytic lleus
      ✓Serum sodium and potassium
      ✓Pain
      Actions to Take Choices
      ✕Administer a proton pump inhibitor
      ✕Administer an NSAID
      ✓Prepare to insert a nasogastric tube
      ✓Make the client NPO
      ✕Offer the client fluid oral rehydration therapy
      Potential Condition Choices
      ✕Peptic Ulcer Disease
      ✕Cholecystitis
      ✓Paralytic lleus
      ✕Gastroenteritis
      Parameters to Monitor Choices
      ✕Yellow skin and mucous membranes
      ✕Hemoglobin and hematocrit
      ✓Serum sodium and potassium
      ✕Skin
      ✓Pain
    3. A nurse is interviewing a pre-operative patient scheduled for a total hip replacement. Which of the following findings would require the nurse to collaborate with the surgeon immediately before sending the patient to the operating room?
      A)The client took phenytoin 100mg with a sip of water at 6 a.m.
      B)The client took metoprolol 25mg with a sip of water at 6 a.m.
      C)The client took half their morning dose of insulin at 6 a.m.
      D)The client took warfarin 2.5mg with a sip of water at 6 a.m.
    4. Pressure injuries can occur to the skin and underlying tissues due to pressure, shear or friction. Which of the following can reduce the incidence of pressure injuries in hospitalized clients? (Select All that Apply.)(SATA)
      A)Inspect the sacrum for blanching
      B)Frequent turning and positioning
      C)Optimizing nutrition
      D)Frequent skin assessments
      E)Maintaining the head of the bed at a 45-degree angle
    Page 3 of 10

    Exam Review

    1. A nurse is planning care for a client who is to receive a competitive neuromuscular blocking agent. Which of the following items should the nurse plan to have at the client's bedside?
      A)Urinary catheter insertion tray
      B)Central venous catheterization tray
      C)Bag-valve-mask device
      D)Temporary pacemaker
    2. A nurse is caring for a client with the diagnosis of clostridium difficile. While providing care to the client, the nurse's glove tears. After removing the soiled gloves, what is the priority action by the nurse?
      A)Wash hands with soap and water
      B)Don a clean pair of nonsterile gloves
      C)Wash hands with alcohol-based hand sanitizer
      D)Wash hands with a bleach wipe from a nearby container
    3. The nurse is assessing a patient with peritonitis. What findings should they expect? (Select All that Apply.)(SATA)
      A)Frequent bowel movements
      B)Inability to pass stools
      C)Hyperactive bowel sounds
      D)Rigid abdomen
      E)Decreased urinary output
    4. Which interventions should the nurse implement to prevent a catheter-associated urinary tract infection (CAUTI)? (Select All that Apply.)(SATA)
      A)Obtain a urine specimen for culture every 24 hours
      B)Flush catheter system daily
      C)Maintain a closed drainage system
      D)Secure the catheter to prevent movement
      E)Begin antibiotics
      F)Inspect urine for color, odor and consistency
    Page 4 of 10

    Exam Review

    1. A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion?
      A)Blood pressure 84/50 mm Hg
      B)Anuria
      C)Petechiae
      D)Confusion
    2. A nurse is caring for a patient who has suffered a major burn. Of the lab values listed, which would be concerning as it is a strong indicator of massive cell destruction?
      A)Calcium 8.0 mg/dL
      B)Glucose 180 mg/dL
      C)Potassium 6.0 mg/dL
      D)Sodium 130 mEq/L
    3. You are caring for a patient with a positive TB skin test (15mm), productive cough for two months, and unintentional weight loss. Which of the following orders will assist with the diagnosis of active tuberculosis? (Select All that Apply.)(SATA)
      A)CBC, BMP, HIV viral load, VDRL
      B)Vital signs every shift
      C)Heart healthy diet
      D)Chest x-ray
      E)Collect specimen x3 mornings for acid-fast bacilli
      F)Admit to a negative pressure room
    4. A nurse is working on a surgical unit and is caring for a client who returned from the Post Anesthesia Care Unit (PACU) 90-minutes ago. Which interventions will decrease the client's risk of developing a pulmonary embolism? (Select All that Apply.)(SATA)
      A)Apply compression stockings
      B)Ambulate the client early
      C)Administer aspirin and warfarin
      D)Maintain the head of the bed at 90 degrees
      E)Encourage client to do active leg exercises
    Page 5 of 10

    Exam Review

    1. A nurse is caring for a client who has burns to approximately 50% of their body. Which of the following physiological changes related to the burns should the nurse anticipate? Select all that apply.(SATA)
      A)Hypermagnesemia
      B)Capillary leak
      C)Loss of protein
      D)Diuresis
      E)Decreased plasma volume
    2. A nurse is teaching a client who has tuberculosis and is to start medication therapy with isoniazid, rifampin and pyrazinamide. Which of the following instructions should the nurse include?
      A)"Take isoniazid with an antacid."
      B)"Drink at least 8 ounces of water when you take the pyrazinamide tablet."
      C)"Expect your sputum cultures to be negative after 6 months of therapy."
      D)"Provide a sputum specimen every 2 weeks to the clinic for testing."
    3. A provider tells the nurse that a patient with a peptic ulcer is being placed on a protein pump inhibitor. Which medication would the nurse anticipate the provider ordering?
      A)Cimetidine
      B)Pantoprazole
      C)Famotidine
      D)Ranitidine
    4. A client is admitted with the diagnosis of Pneumocystis carinii peneumonia. Which nursing diagnosis has the highest priority?
      A)Impaired oral mucous membranes
      B)Impaired gas exchange
      C)Imbalanced nutrition: less than body requirements
      D)Activity intolerance
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