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    Exam Review

    1. Parents of an adolescent client experiencing a relapse of leukemia do not want the client to know about the relapse. Which of the following ethical principles must a nurse consider when the client asks about their medical status?
      A)Fidelity
      B)Authority
      C)Justice
      D)Veracity
    2. A nurse is discussing informed consent with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the information?
      A)"A client must sign an Against Medical Advice form if he withdraws consent."
      B)"A client can withdraw consent at any time after signing the informed consent form."
      C)"A client who is involuntarily admitted to a mental health unit cannot withdraw consent for treatment.
      D)"A client must provide a written refusal for a procedure for which he has already signed an informed consent."
    3. A nurse is assisting with the care of a client who is pregnant. Complete the diagram by dragging from the choices below to specify what condition the client is meet likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to determine the client's progress.
      ✓Prepare the client for suction curettage
      ✓Remind the client that weekly blood tests are needed to measure pregnancy hormone
      ✓Hydatidiform mole
      ✓Vaginal bleeding
      ✓Blood pressure
      Actions to Take Choices
      ✕Prepare the client for an emergency caesarean birth
      ✓Prepare the client for suction curettage
      ✕Anticipate a prescription for methotrexate
      ✓Remind the client that weekly blood tests are needed to measure pregnancy hormone
      ✕Administer terbutaline
      Potential Condition Choices
      ✕Vaginal bleeding
      ✓Hydatidiform mole
      ✕Ectopic pregnancy
      ✕Abruptio placentae
      ✕Placenta previa
      Parameters to Monitor Choices
      ✓Vaginal bleeding
      ✓Blood pressure
      ✕Uterus for hypertonicity
      ✕Unilateral pelvic pain
      ✕Cervical dilation per provider
    4. A nurse is assisting in the care of a client in an outpatient mental health clinic.
      (Highlight — findings requiring follow-up are marked)

      A nurse is assisting in the care of a client in an outpatient mental health clinic.

      Click to highlight the findings that indicate the client is experiencing adverse effects of the medication. To deselect a finding, click on the finding again.

      Nurses' Notes

      Today:

      Client states, "I'm feeling much better." They report less fatigue, even though they have difficulty sleeping. Client reports they are not sad anymore but are experiencing more frequent headaches. Client continues to deny any suicidal ideation.

      Vital Signs

      Today:

      Blood pressure 169/91 mm Hg

      Heart rate 78/min

      Respiratory rate 18/min

    Page 1 of 45

    Exam Review

    1. A nurse is assisting with a quality improvement project to decrease client falls. Which of the following activities should the nurse perform?
      A)Document an incident report in a client's medical record.
      B)Notify the provider if a client fails
      C)Assist with the care of a client who has fallen.
      D)Collect data about each fall
    2. A nurse in a long-term care facility is assisting in planning care for a group of clients. For which of the following clients can the nurse safely gait belt?
      A)A client who is displaying aggression
      B)A client who has had chest trauma.
      C)A client who has limited arm strength.
      D)A client who has a thoracic incision.
    3. A nurse is assisting with the care of a preschooler who is postoperative following an appendectomy. Complete the following sentence by using the lists of options. The pre-schooler is at risk for developing ▾ pneumonia evidenced by the pre-schooler's ▾ shallow breathing
      Dropdown 1:
      Option 1: pneumonia
      Option 2: wound infection
      Option 3: ileus
      Dropdown 2:
      Option 1: shallow breathing
      Option 2: increasing temperature
      Option 3: hypoactive bowel sounds
    4. A nurse is assisting with the care of a client. Select 1 condition and 1 finding to fill in each blank in the following  sentence. The client likely suffered from  ▾ opioid intoxication as evidenced by   ▾ pupil characteristics
      Dropdown 1:
      Option 1: alcohol withdrawal
      Option 2: hallucinogen intoxication
      Option 3: opioid intoxication
      Option 4: opioid withdrawal
      Dropdown 2:
      Option 1: amount of alcohol consumed
      Option 2: breath sounds
      Option 3: abdominal findings
      Option 4: pupil characteristics
      Option 5: current temperature
    Page 2 of 45

    Exam Review

    1. A nurse is caring for a client who is 1 day postoperative following a total hip arthroplasty and is receiving heparin subcutaneously. Which of the following adverse effects of the medication should the nurse report to the provider?
      A)Anorexia
      B)Epistaxis
      C)Weight gains
      D)Bradycardia
    2. A nurse is assisting with the care of a client in a medical-surgical unit. Which of the following actions should the nurse take to decrease the risks for a urinary tract infection for this client? Select all that apply.(SATA)
      A)Review the need for the indwelling urinary catheter daily
      B)Empty the drainage bag when it is half full
      C)Use soap and water to provide perineal care
      D)Place the drainage bag on the bed when transporting the client
      E)Encourage the client to drink 1000 ml of fluid daily
      F)Change the indwelling urinary catheter tubing every 3 days.
    3. A nurse is assisting in the discharge planning of an infant who has a spica cast. Which of the following equipment needs should the nurse identify for discharge?
      A)Urinary catheter
      B)Wound vac
      C)Car seat
      D)Feeding pump
    4. A nurse in a provider's office is collecting data from a client who has psoriasis. Which of the following statements by the client should the nurse report to the provider?
      A)"I limit my time spent out in the sunlight
      B)"I try not to look at the scales on my body."
      C)"I remove old medication on my skin before applying a new dose."
      D)"I do not use fabric softener when I wash my clothing"
    Page 3 of 45

    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)Empty the collection chamber every 8 hr
      C)Ensure the device is kept below the level of the client's chest.
      D)Clamp the chest tube every 4hr
    2. A nurse is reinforcing teaching for a client regarding long-acting reversible contraception options. Which of the following client statements indicate an understanding of the teaching?
      A)"If I decide to get implants in my arm, I will get them replaced every 10 years."
      B)"If I decide to get pregnant again, tubal reconstruction is a reliable option
      C)"I get the birth control injection, I will need an injection 4 times a year."
      D)"If I get an IUD placed. I will not have menstrual bleeding”
    3. A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate. The nurse notes clots and dark red blood in the catheter collection bag. Which of the following actions should the nurse take?
      A)Clamp the urinary catheter tubing.
      B)Replace the indwelling urinary catheter with a smaller diameter catheter
      C)Irrigate the bladder with 20 to 30 mL of 0.9% sodium chloride irrigation
      D)Allow the tubing to hang below the drainage bag
    4. A nurse is assisting in planning care for a 16-year-old client in a pediatric clinic. Which of the following actions would be a breach of confidentiality?
      A)Reviewing the results of the client's chlamydia screening with their parents, without the client's consent.
      B)Reviewing the results of the client's celiac screening with their parents, without the client's consent.
      C)Reviewing the results of the client's complete blood count (CBC) with their parents, without the client's consent
      D)Reviewing the results of the client's urinalysis with their parents, without the client's consent.
    Page 4 of 45

    Exam Review

    1. A nurse is assisting with the care of client who is 6 hr postoperative. Which of the following findings should the nurse report to the provider?
      A)Serosanguinous drainage on dressing
      B)Hypoactive bowel sounds
      C)Urinary output of 25 mL/hr
      D)Pain level of 2 on 0 to 10 scale
    2. A nurse is reinforcing teaching with a client about the use of budesonide for asthma management. Which of the following statements by the adolescent indicates an understanding of the teaching?
      A)"I will take my inhaler treatment before each meal and at bedtime."
      B)"I should use my inhaler before exercising”
      C)"I should use my inhaler when I have an asthma attack"
      D)"I will rinse my mouth and gargle with water after each inhaler treatment."
    3. A nurse is caring for a client who is at 34 weeks of gestation. Which of the following statements by the client is the nurse's priority to report to the provider?
      A)“I have nosebleeds once per week"
      B)"My heart feels like it skips a beat”
      C)“I am experiencing persistent headaches."
      D)The palms of my hands are red and blotchy”
    4. A nurse is caring for a client who is confused and is trying to pull out their IV catheter. After attempting other measures to prevent the client from self-harm, the nurse places wrist restraints on the client. Which of the following actions should the nurse take?
      A)Contact the provider within 48 hr to obtain a prescription for the restraints.
      B)Remove the restraints from the client's wrists every 2 hr
      C)Check that one finger will fit between the client's wrists and the restraints.
      D)Fasten the restraints' ties to the bed's side rails.
    Page 5 of 45

    Exam Review

    1. A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The client is incontinent of stool and urine. Which of the following actions should the nurse take to prevent skin breakdown?
      A)Use a moisture barrier on the client's skin.
      B)Clean the client's skin with soap and hot water.
      C)Message the area around the client's coccyx.
      D)Limit the client's fluid intake
    2. A nurse is assisting in the care of a client who has a fractured femur and is in Buck's traction. Which of the following actions should the nurse take?
      A)Apply a 9 kg 120 lb weight to the traction
      B)Clean the pin insertion sites on a daily basis.
      C)Remove the weights while the client is eating
      D)Ensure that the weights are hanging freely.
    3. A nurse is reinforcing teaching with a group of clients about taking recommended folic acid supplements prior to conception and throughout pregnancy as primary prevention. Which of the following conditions can occur in the neonate as the result of folic acid deficiency?
      A)Hyperbilirubinemia
      B)Hyperemesis gravidarum
      C)Iron deficiency anemia
      D)Neural tube defects
    4. A nurse is making client assignments for the next shift. The nurse should assign which of the following clients to the assistive personnel?
      A)A client who requires sterile dressing changes every three hours
      B)A client who has a small bowel obstruction and requires insertion of a nasogastric tube
      C)A client who is postoperative and requires intake and output measurement every 2 hr
      D)A client on hospice who is unstable and requires frequent vital sign checks
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