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    Exam Review

    1. A nurse is teaching a client who is postpartum and has a new prescription for an injection of Rho (D) immunoglobulin. Which of the following should be included in the teaching?
      A)It prevents the formation of Rh antibodies in mothers who are Rh negative.
      B)It prevents the formation of Rh antibodies in newborns who are Rh positive.
      C)It destroys Rh antibodies in newborns who are Rh positive.
      D)It destroys Rh antibodies in mothers who are Rh negative.
    2. A nurse is preparing to administer acetaminophen 10 mg/kg/dose to a child who weighs 28 lb. The amount available is acetaminophen 120 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) _______ mL
    3. A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point. (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)
      Correct Answer:"{\"xRanges\":[40.419407894736835,42.61239035087719],\"yRanges\":[52.569444378217064,54.65277771155039]}"
    4. A nurse is talking with a client whose thyroid-stimulating hormone (TSH) level will be measured. Which of the following statements by the nurse explains the purpose of this test?
      A)"This test measures the absorption of iodine and how it relates to the thyroid gland."
      B)"This test determines whether your thyroid gland is overactive, appropriately active, or underactive."
      C)"This test detects antithyroid antibodies in your blood."
      D)"This test measures the amount of thyroid hormone that attaches to a protein in your blood."
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    Exam Review

    1. A nurse is caring for a child who has suspected appendicitis. Which of the following provider prescriptions should the nurse clarify?
      A)Administer sodium biphosphate/sodium phosphate.
      B)Monitor oral temperature every 4 hr.
      C)Maintain NPO status.
      D)Medicate the client for pain every 4 hr as needed.
    2. A nurse in an emergency department is caring for an adolescent following a suicide attempt. After reviewing the client's history, the nurse should determine that which of the following is the priority risk factor for suicide completion?
      A)Previous suicide attempt
      B)Loss of a parent
      C)Active psychiatric disorder
      D)History of substance abuse
    3. A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?
      A)Insert a gloved hand into the vagina to relieve pressure on the cord.
      B)Cover the cord with a sterile, moist saline dressing.
      C)Prepare the client for an immediate birth.
      D)Place the client in knee-chest position.
    4. A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?
      A)Administer an intravenous antibiotic.
      B)Obtain blood cultures.
      C)Prepare the child for a lumbar puncture.
      D)Place the child in isolation.
    Page 2 of 17

    Exam Review

    1. A nurse is assessing an 8-month-old infant for cerebral palsy. Which of the following findings is a manifestation of the condition?
      A)Smiles when a parent appears
      B)Sits with pillow props
      C)Tracks an object with eyes
      D)Uses a pincer grasp to pick up a toy
    2. A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?
      A)3+ protein in the urine
      B)Deep tendon reflexes of +1
      C)1+ pitting sacral edema
      D)Blood pressure 148/98 mm Hg
    3. A nurse is assessing a 3-year-old child who has aortic stenosis. Which of the following findings should the nurse expect? (Select all that apply.)(SATA)
      A)Weak pulses
      B)Murmur
      C)Hypotension
      D)Bradycardia
      E)Clubbing of the nail beds
    4. A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?
      A)Encourage the client to empty her bladder.
      B)Increase the frequency of fundal massage.
      C)Notify the client's provider.
      D)Document the findings and continue to monitor the client.
    Page 3 of 17

    Exam Review

    1. A nurse is caring for a newly admitted client. Exhibits A nurse notes the client's condition and initiates the following action. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
      ✓Assess for asterixis
      ✓Administer lactulose as prescribed
      ✓Encephalopathy
      ✓Intake and output
      ✓Neurologic status
      Actions to Take
      ✕Educate the client about protein Intake
      ✕Prepare for a paracentesis
      ✕Monitor for hematemesis
      ✓Assess for asterixis
      ✓Administer lactulose as prescribed
      Condition Most Likely Experiencing
      ✕Esophageal varices
      ✕Pruritus
      ✓Encephalopathy
      ✕Ascites
      Parameters to Monitor
      ✓Intake and output
      ✕Skin integrity
      ✕Safety measures
      ✕Bleeding
      ✓Neurologic status
    2. A nurse is assessing an older adult client who is receiving digoxin. The nurse should recognize that which of the following findings is a manifestation of digoxin toxicity?
      A)Photosensitivity
      B)Ataxia
      C)Anorexia
      D)Jaundice
    3. A client becomes very dejected and states, "No one really cares what happens to me. Life isn't worth living anymore." Which of the following responses should the nurse make?
      A)"Why do you feel that way?"
      B)"Of course, people care. Your family comes to visit every day."
      C)"Tell me who you think doesn't care about you."
      D)"I care about you, and I am concerned that you feel so sad."
    4. A nurse is caring for a child who is 2 hr postoperative following a tonsillectomy. Which of the following fluid items should the nurse offer the child at this time?
      A)Cranberry juice
      B)Vanilla milkshake
      C)Orange juice
      D)Crushed ice
    Page 4 of 17

    Exam Review

    1. A community health nurse is providing teaching to the family of a client who has primary dementia. Which of the following manifestations should the nurse tell the family to expect?
      A)Forgetfulness gradually progressing to disorientation
      B)Decreased auditory and visual acuity
      C)Personality traits that are opposite of original traits
      D)Decreased display of emotions
    2. A nurse is obtaining informed consent from a client who is preoperative. Which of the following actions should the nurse take? (Select all that apply.)(SATA)
      A)Validate the signature is authentic.
      B)Confirm that the consent is voluntary.
      C)Establish that the client is able to pay for the surgical procedure.
      D)Verify the client understands the surgical procedure.
      E)Explain the surgical procedure to the client.
    3. A public health nurse is assessing an older adult client who lives with a family member. The nurse identifies several bruises in various stages of healing. The client and family member explain that the bruises are a result of clumsiness. However, based on the distribution of the bruises, the nurse suspects abuse. Which of the following actions should the nurse take first?
      A)Report the findings to a supervisor.
      B)Discuss respite care with the client's family.
      C)Document the bruises in the client's chart.
      D)Provide the client with a crisis hotline number.
    4. A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take?
      A)Instruct the client to sit down and stop pacing.
      B)Walk with the client at a gradually slower pace.
      C)Allow the client to pace alone until physically tired.
      D)Have a staff member escort the client to her room.
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    Exam Review

    1. A nurse is teaching a client who has gastroesophageal reflux disease about managing his illness. Which of the following recommendations should the nurse include in the teaching?
      A)Avoid eating within 3 hr of bedtime.
      B)Limit fluid intake not related to meals.
      C)Chew on mint leaves to relieve indigestion.
      D)Season foods with black pepper.
    2. A nurse is teaching a client how to draw up regular insulin and NPH insulin into the same syringe. Which of the following instructions should the nurse include?
      A)Discard regular insulin that appears cloudy.
      B)Shake the NPH insulin until it is well mixed.
      C)Draw up the NPH insulin into the syringe first.
      D)Inject air into the regular insulin first.
    3. A nurse is caring for a client who has a positive pregnancy test. The nurse is teaching the client about common discomforts in the first trimester of pregnancy as well as warning signs of potential danger. The nurse should instruct the client to call the clinic if she experiences which of the following manifestations?
      A)Facial edema
      B)Nausea and vomiting
      C)Urinary frequency
      D)Leukorrhea
    4. A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.)(SATA)
      A)Deep respirations
      B)Clubbing of the fingers
      C)Dyspnea
      D)Barrel chest
      E)Bradycardia
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