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    Exam Review

    1. The nurse receives a patient status post abdominal surgery into the post-anesthesia care unit (PACU). The patient was just extubated with an indwelling urethral catheter, a midline abdominal dressing, and an IV. What action should the nurse prioritize?
      A)Check the surgical dressing for bleeding
      B)Assess the patient’s pain and intensity
      C)Examine the IV site for redness or infiltration
      D)Assess the patient’s respiratory status
    2. The nurse is obtaining the health history of a patient who has iron deficiency anemia. Which factor in this patient’s history would the nurse correlate with this diagnosis?
      A)Family history of sickle cell disease
      B)Eating a meat-free diet
      C)History of leukemia
      D)History of bleeding ulcer
    3. A patient presents to the emergency department with a thoracic aortic aneurysm. Which findings would the nurse find most consistent with this condition? (Select all that apply)(SATA)
      A)Shortness of breath
      B)Difficulty swallowing
      C)Chest pain
      D)Back pain
      E)Hoarseness
    4. A nurse in a hematology clinic is working with four patients who have polycythemia vera. Which patient would the nurse assess first?
      A)Patient who reports calf tenderness and swelling
      B)Patient with a swollen and painful left great toe
      C)Patient who reports shortness of breath
      D)Patient with a blood pressure of 180/98 mm Hg
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    Exam Review

    1. Which of the following patients exhibits signs and symptoms consistent with cystic fibrosis?
      A)Lung sounds with audible wheezes and dyspnea
      B)Difficulty breathing when speaking, dyspnea, and a chronic cough
      C)Steatorrhea, chest congestion, and limited exercise tolerance
      D)Sudden absence of wheezing and low SpO2
    2. Which important aspect of coordinating care within the interdisciplinary team is facilitated by the use of SBAR?
      A)Coordination
      B)Supervision
      C)Communication
      D)Delegation
    3. A visiting nurse is in the home of an older adult and notes a 7-pound weight loss since last month's visit. What actions should the nurse perform first? (Select all that apply)(SATA)
      A)Call Adult Protective Services and file a report of family neglect
      B)Assess oral health and determine if the patient has dentures that fit appropriately
      C)Encourage the patient to continue the current exercise plan
      D)Assess the patient's nutritional status
      E)Ask the patient what they have eaten in the last week
    4. An RN has delegated measurement and documentation of hourly intake and outputs (I&Os) on the cardiac care unit to a certified nurse assistant (CNA). Which principle of delegation applies in this situation?
      A)The nurse is accountable for duties that are delegated to unlicensed personnel
      B)The nurse is required to perform the delegated task with the unlicensed personnel
      C)The nurse is not required to follow up because the CNA knows what to do
      D)The nurse is responsible for ensuring the CNA is competent to perform I&Os
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    Exam Review

    1. A nurse is caring for an older adult patient who has been admitted for exacerbation of left-sided heart failure. Which of the following assessment findings should the nurse anticipate?
      A)Dependent edema
      B)Jugular vein distention
      C)Polyuria at night
      D)Frothy sputum
    2. The patient with significant diarrhea due to a Clostridium difficile infection is at risk for which electrolyte imbalance?
      A)Hyperkalemia
      B)Hypokalemia
      C)Hypocalcemia
      D)Hyponatremia
    3. An arterial blood gas report indicates the patient’s pH is 7.50, PaCO2 is 30 mm Hg, and HCO3 is 23 mEq/L. How would the nurse interpret these results?
      A)Respiratory acidosis
      B)Metabolic alkalosis
      C)Respiratory alkalosis
      D)Metabolic acidosis
    4. A student nurse is preparing an IV push dose of furosemide 80 mg. Which lab value would cause the student to question administering the medication?
      A)Potassium 3.0 mEq/L
      B)Phosphorus 4.0 mg/dL
      C)Sodium 145 mEq/L
      D)Calcium 10.2 mg/dL
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    Exam Review

    1. A nurse admits a patient with community-acquired pneumonia. Which medical order should the nurse implement first?
      A)Cefazolin (Ancef) 1 g IV every 8 hours
      B)Postural drainage and percussion twice a day
      C)Sputum for culture and sensitivity
      D)Albuterol nebulizer treatments every 6 hours
    2. The physician orders ampicillin 2 grams in 50 ml of normal saline to infuse over 30 minutes, and the drop factor on the tubing is 15 gtt/ml. How many gtt/min will the nurse administer?
      A)25 gtt/min
      B)19 gtt/min
      C)21 gtt/min
      D)20 gtt/min
    3. A nurse is assessing a patient who is at risk for deep-vein thrombosis (DVT). Which of the following findings is a manifestation of DVT?
      A)Auscultation of bruit over pedal pulse
      B)Pallor in the affected extremity
      C)Groin tenderness
      D)Cramping pain in one foot
    4. A patient presents in sickle cell disease crisis. What intervention by the nurse takes priority?
      A)Administer oxygen
      B)Start an IV line
      C)Initiate pulse oximetry
      D)Give pain medication
    Page 4 of 12

    Exam Review

    1. A nurse is providing discharge instructions for a client who has congestive heart failure. Which of the following client statements indicates to the nurse that the teaching was effective?
      A)I will take my diuretic before sleep and drink fluids during the day
      B)I plan to slow down if I am tired the day after exercising
      C)I will read food labels and limit my sodium to 4 grams per day
      D)I should use naproxen to manage discomfort
    2. A patient has just been diagnosed with pulmonary tuberculosis and will be discharged with a prescription for isoniazid 300 mg orally daily. At what time would the nurse teach this patient to take this medication?
      A)An hour before breakfast
      B)Immediately before breakfast
      C)An hour before bedtime
      D)Immediately after breakfast
    3. What conditions predispose an older adult patient to acute confusion or delirium? (Select all that apply)(SATA)
      A)Electrolyte imbalance
      B)Administration of antibiotics
      C)Polypharmacy
      D)Vegetarian diet
      E)Acute infection
    4. A pulmonary nurse cares for patients who have chronic obstructive pulmonary disease (COPD). Which patient would the nurse assess first?
      A)A 52-year-old in a tripod position using accessory muscles to breathe
      B)A 74-year-old with a chronic cough and thick tenacious secretions
      C)A 46-year-old with a 30-pack-year history of smoking
      D)A 68-year-old with lower extremity edema and clubbed fingers
    Page 5 of 12

    Exam Review

    1. A nurse is caring for a patient who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the patient is developing this condition?
      A)Breathlessness
      B)Ascites
      C)Weight gain
      D)Peripheral edema
    2. The nurse knows that the pathway for circulating debris or venous stasis within the blood itself that can activate platelets and trigger the clotting cascade is called
      A)Coagulation pathway
      B)Virchow's triad
      C)Extrinsic pathway
      D)Intrinsic pathway
    3. A nurse is assessing a patient who has suffered a nasal fracture. Which assessment would the nurse perform first?
      A)Vital signs
      B)Airway patency
      C)Facial pain
      D)Bone displacement
    4. A nurse is prioritizing care for multiple patients. Which action should the nurse prioritize?
      A)Positioning a client who has just returned from hip surgery
      B)Increasing the oxygen flow rate for a client who has wheezing
      C)Taking vital signs
      D)Assessing a client who reports new-onset chest pain
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