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    Exam Review

    1. Which of the following statements should a nurse make when providing discharge teaching to a new parent about breastfeeding her infant?
      A)Supplement breastfeedings with water every 12 hours.
      B)Offer your infant the breast when he shows signs of hunger.
      C)Limit the time your infant feeds to 10 minutes on each breast.
      D)Begin each feeding using the same breast.
    2. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?
      A)Uterine contractions
      B)Vomiting
      C)Hypertension
      D)Polyuria
    3. A nurse on a medical-surgical unit is performing medication reconciliation for a newly admitted client. Which of the following actions should the nurse take?
      A)Compare the medication label to the provider’s prescription on three occasions before administration.
      B)Compare the client’s list of home medications to the admission prescriptions written for the client.
      C)Administer medications to treat a condition to the actual prescriptions.
      D)Ensure the medication is administered within 3 hours of the scheduled time.
    4. A nurse is caring for a client who has an end-stage lung disease. The client requests not to be resuscitated if their condition worsens. Which of the following actions should the nurse take?(SATA)
      A)Explain to the client what it means to change their code status.
      B)Place a sign with “Do Not Resuscitate” outside the client’s room.
      C)Obtain consent from the family to change the plan of care.
      D)Document the client’s request in the medical record.
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    Exam Review

    1. A community health nurse is performing a home visit for a client and is evaluating the home environment for safety. Which of the following findings would indicate to the nurse that the client has a proper understanding of safety in the home?
      A)A single light fixture hangs along the sidewalk to the house.
      B)The batteries in the smoke alarms are changed annually.
      C)A small area rug is placed at the front door.
      D)Electrical cords are secured under furniture.
    2. A nurse is conducting a workshop on the importance of interprofessional collaboration. Which of the following is included in the tertiary prevention phase in interprofessional care?
      A)Conducting routine health screenings for early disease detection.
      B)Administering vaccinations to prevent infectious diseases.
      C)Developing a rehabilitation plan for a client post-stroke.
      D)Educating a community about healthy lifestyle choices.
    3. A nurse is providing education to a client who is scheduled for a left knee arthroplasty. Which of the following statements regarding informed consent indicates client understanding of the teaching?
      A)Can you tell me more about the surgery I am having?
      B)I will ask the doctor about my surgery when I get into the operating room.
      C)I understand the risks and benefits of the procedure and agree to it.
      D)My family will sign the consent form for me.
    4. A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?
      A)Occasional mild nausea
      B)Swelling of the ankles in the evening
      C)Vaginal bleeding
      D)Increased appetite
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    Exam Review

    1. A nurse has been assigned to an internal disaster drill team and is triaging clients. Which of the following clients should the nurse classify with a green tag?
      A)A client who has multiple facial lacerations.
      B)A client who has a puncture wound in the right lower lung.
      C)A client who has full-thickness burns over the lower extremities.
      D)A client who has an open compound fracture of the humerus.
    2. A nurse is caring for a client who has cancer and is being transferred to hospice care. The client’s daughter tells the nurse, “I’m not sure what to say to my mom if she asks me about dying.” Which of the following responses by the nurse is appropriate? (Select all that apply)(SATA)
      A)Tell her not to worry about it right now.
      B)You sound like you have questions about your mom dying. Let’s talk about it.
      C)Let’s talk about your mom’s cancer and what it means.
      D)Encourage her to focus on the present and not think about dying.
    3. A nurse is flushing a client’s intermittent infusion device. The client states, “Why do you have to do that if you are not giving me medicine?” Which of the following statements should the nurse make?
      A)This prevents leakage of fluid and medication.
      B)This helps to keep you hydrated.
      C)This clears blood from the line.
      D)This ensures the device is sterile.
    4. A nurse is teaching a client who has an ileostomy about the care of their stoma. Which of the following statements by the client indicates an understanding of the teaching?
      A)I should change my stoma pouch 30 minutes after meals.
      B)I should cut my pouch opening 1/8 inch larger than my stoma.
      C)I should clean my stoma with moisturizing soap.
      D)I should expect my stoma to be blistered.
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    Exam Review

    1. A nurse is teaching about preventing constipation to a client who has a new prescription for oxycodone. Which of the following statements by the client indicates an understanding of the teaching?
      A)I will decrease my fluid intake to make my stools firmer.
      B)I will increase my dietary fiber intake.
      C)I will take a laxative only when I feel constipated.
      D)I will exercise less to conserve energy.
    2. A nurse is preparing to administer medication to a client. Which of the following actions should the nurse take?
      A)Use two identifiers to verify the client’s identity.
      B)Check the label of the medication twice.
      C)Ensure the medication is administered within 3 hours of the scheduled time.
      D)Administer medications to treat a condition to the actual prescriptions.
    3. A nurse is planning to transfer a client who weighs 136 kg (300 lb) from a bed to a chair. The client is unable to assist in the transfer. Which of the following actions should the nurse plan to take?
      A)Use a mechanical lift to transfer the client.
      B)Ask another nurse to assist with the transfer.
      C)Position the client upright before transferring.
      D)Use a sliding board to transfer the client.
    4. A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan?
      A)Place the client upright on a donut-shaped cushion.
      B)Turn and reposition the client every 15 minutes while sitting.
      C)Apply a moisture-barrier cream to the affected area.
      D)Turn and reposition the client every 3 hours while in bed.
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    Exam Review

    1. A nurse is reviewing the medical record of a client who had abdominal surgery 2 days ago. The nurse should identify that which of the following findings indicates the client is at risk for delayed wound healing?
      A)Pain level of 1 on a scale of 0 to 10
      B)Oxygen saturation of 92% on room air
      C)Albumin level of 2.5 g/dL
      D)Body mass index of 22
    2. A nurse is caring for a client who has a closed wound drainage system. Which of the following interventions should the nurse perform to assess the amount of drainage?
      A)Mark the drainage output on the collection chamber every 48 hours.
      B)Strip the chest tube vigorously to dislodge blood clots.
      C)Maintain the collection chamber below the client’s chest.
      D)Add water to the water seal chamber as it evaporates.
    3. A nurse is caring for a client who has experienced a stillbirth. Which of the following actions should the nurse take?
      A)Assure the client that she can have additional children.
      B)Avoid talking to the client about the newborn.
      C)Discourage the client from allowing friends to see the newborn.
      D)Offer to take pictures of the newborn for the client.
    4. A nurse at a community health clinic is planning care for an adolescent who recently learned that she is pregnant and is concerned about her ability to afford and care for her baby. Which of the following actions should the nurse take?
      A)Refer the adolescent to a local mental health clinic.
      B)Contact the adolescent’s parent for assistance.
      C)Assist the adolescent in applying for Medicaid.
      D)Advise the adolescent to place the newborn for adoption.
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    Exam Review

    1. A nurse is caring for a client who has increased intracranial pressure following a traumatic brain injury. Which of the following actions should the nurse take? (Select all that apply)(SATA)
      A)Provide a quiet environment for the client.
      B)Obtain client vital signs every 8 hr.
      C)Encourage the client to cough and deep breathe.
      D)Maintain the head of the bed at a 30-degree angle.
      E)Administer stool softeners to the client.
    2. A nurse is assessing a client’s pulmonary artery wedge pressure (PAWP). The nurse should recognize that an elevated PAWP indicates which of the following complications?
      A)Cardiogenic shock
      B)Left ventricular failure
      C)Hypotension
      D)Hypovolemia
    3. A nurse is performing an abdominal assessment as part of a client’s comprehensive physical examination. Which of the following is the final step the nurse should perform?
      A)Percussion
      B)Auscultation
      C)Palpation
      D)Inspection
    4. A nurse is assessing a client who has a brain tumor and is receiving palliative care. Which of the following findings indicates the nurse should administer pain medication?
      A)Cheyne-Stokes respirations
      B)Mottled skin
      C)Constricted pupils
      D)Grimacing
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