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    Exam Review

    1. A nurse is caring for a client at a clinic. Exhibits Complete the following sentence by using the lists of options. The client is at risk for developing ▾ serotonin syndrome due to ▾ adverse effects of paroxetine.
      Dropdown 1:
      Option 1: psychosis
      Option 2: serotonin syndrome
      Option 3: mania
      Dropdown 2:
      Option 1: adverse effects of paroxetine
      Option 2: Anxiety
      Option 3: Fluoxetine discontinuation
    2. A nurse is providing teaching at a community health fair about electrical fire prevention. Which of the following information should the nurse Include in the teaching?
      A)"Remove a plug from the socket by pulling the cord."
      B)"Use three-pronged grounded plugs."
      C)"Check for a tingling sensation around the cord."
      D)"Cover extension cords with a rug."
    3. A nurse is assessing a client who was placed in restraints for aggressive behavior. The client is now calm and cooperative. Which of the following actions should the nurse take?
      A)Encourage the client to attend a group therapy session.
      B)Continue to monitor the client every 15 min.
      C)Remove the restraints from the client.
      D)Offer the client PRN pain medication.
    4. A nurse is assessing a 3-month-old infant whose parents report starting cow's milk feedings 1 week ago. Which of the following actions should the nurse take?
      A)Instruct the parent to give 5 mcg of vitamin D daily.
      B)Instruct the parent to give the infant water every 3 hr between feedings.
      C)Advise the parent to avoid giving cow's milk to the infant prior to 1 year of age.
      D)Recommend the parent mix the milk with rice cereal for feedings.
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    Exam Review

    1. A nurse is caring for a client who is experiencing a postpartum hemorrhage and has a history of hypertension. Which of the following medications is contraindicated for this client?
      A)Misoprostol
      B)Oxytocin
      C)Terbutaline
      D)Methylergonovine
    2. A nurse is performing an annual wellness exam on an 8-year-old child whose last exam was one year ago. Which of the following findings should the nurse report to the provider?
      A)Drinks 3 cups of 1% milk per day
      B)Weight has increased by 5 kg (11 lb)
      C)Height has increased by 3.8 cm (1.5 in)
      D)Consumes three meals and two snacks per day
    3. A nurse is caring for a client in the outpatient health clinic. Exhibits For each potential nursing intervention, click to specify if the intervention is indicated or not indicated.
      IndicatedNot Indicated
      Instruct client to avoid foods that have been fermented or aged.✓
      Encourage client to sleep until later in the morning.✓
      Advise client to notify provider if pregnant.✓
      Encourage high-calorie finger foods.✓
      Advise client to rise slowly from sitting position.✓
      Encourage naps during the day when client is tired.✓
      Encourage a regular sleep-wake schedule.✓
    4. A nurse in an acute care facility is caring for a toddler. Exhibits For each assessment finding below, click to specify if the assessment finding is consistent with Crohn's disease, appendicitis, or intussusception. Each finding may support more than 1 disease process.
      Crohn's diseaseAppendicitisIntussusception
      Temperature✓✓
      Vomiting✓✓✓
      Pain rating✓✓
      Abdominal findings✓✓
      Stool✓✓
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    Exam Review

    1. A nurse is assessing a group of clients at risk of developing a pressure injury. The nurse should identify that which of the following clients is at the greatest risk?
      A)A client who has dementia and is incontinent of urine
      B)A client who is 2 days postoperative following orthopedic surgery
      C)A client who has a T-tube following an open cholecystectomy
      D)A client who has had a recent myocardial infarction
    2. A nurse is caring for a toddler in the outpatient setting. Exhibits Complete the following sentence by using the lists of options. The nurse recognizes the toddler has likely developed ▾ Reye's syndrome due to ▾ aspirin administration.
      Dropdown 1:
      Option 1: gastroenteritis
      Option 2: Reye's syndrome
      Option 3: bronchitis
      Dropdown 2:
      Option 1: acetaminophen administration
      Option 2: oseltamivir administration
      Option 3: aspirin administration
    3. A nurse is caring for a client who has a closed wound drainage system. Which of the following interventions should the nurse include in the plan of care?
      A)Change the drainage tubing every 48 hr.
      B)Observe for drainage flow through the tubing.
      C)Remove the drain if output from the drain increases.
      D)Irrigate the drain to maintain suction.
    4. 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)Auscultation
      B)Inspection
      C)Palpation
      D)Percussion
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    Exam Review

    1. A nurse is assessing a client who has end-stage kidney disease. Which of the following findings should the nurse expect? (Select all that apply.)(SATA)
      A)Anemia
      B)oliguria
      C)Hypotension
      D)Bradypnea
      E)Edema
    2. A nurse is caring for a client who is to undergo a bilateral prophylactic mastectomy. The client states that her family opposes her decision. Which of the following responses should the nurse make?
      A)"Your family disagrees with your decision?"
      B)"Did you tell your provider that your family doesn't agree with your decision?"
      C)"You are making the same decision I would make."
      D)"You should get your family to agree with your decision before signing the consent."
    3. A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply.)(SATA)
      A)Keep objects in the client's room in the same place.
      B)Ensure there is high-wattage lighting in the client's room.
      C)Touch the client gently to announce presence.
      D)Approach the client from the side.
      E)Allow extra time for the client to perform tasks.
    4. A nurse is preparing to administer labetalol 40 mg IV to a client. Available is labetalol 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
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    Exam Review

    1. A nurse on a medical-surgical unit is caring for a client. Exhibits
      ✓Educate the client about sodium restriction
      ✓Obtain a prescription for a diuretic
      ✓Heart failure
      ✓Daily weight
      ✓Blood pressure
      Actions to Take Choices
      ✓Educate the client about sodium restriction
      ✕Administer antibiotics as prescribed.
      ✕Prepare the client for cardioversion
      ✓Obtain a prescription for a diuretic
      ✕Educate the client about valve replacement
      Potential Condition Choices
      ✕Endocarditis
      ✓Heart failure
      ✕Aortic stenosis
      ✕Mitral stenosis
      Parameters to Monitor Choices
      ✕Skin lesions
      ✕Blood cultures
      ✓Daily weight
      ✕Fever
      ✓Blood pressure
    2. A nurse is providing care for a client who is scheduled for electroconvulsive therapy. Which of the following conditions should the nurse identify as an increased risk for complications?
      A)Subdural hematoma
      B)Renal calculi
      C)Hyperthyroidism
      D)Diabetes mellitus
    3. A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take?
      A)Call in additional medical-surgical unit nursing care staff.
      B)Act as a liaison between the facility and the media.
      C)Determine the medical needs of incoming clients through the emergency department.
      D)Recommend to the provider specific acute care clients for discharge.
    4. 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 helps to keep you hydrated."
      B)"This clears blood from the tubing and the catheter."
      C)"This makes sure it stays sterile."
      D)"This prevents leakage of fluid and medication."
    Page 5 of 44

    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)Capillary refill time 1 second
      C)BMI 35
      D)Oxygen saturation 97% on room air
    2. A nurse is preparing to obtain a blood specimen from a preschooler. Which of the following actions should the nurse perform?
      A)Collect 4 mL/kg of blood in a 24-hr period.
      B)Apply lidocaine cream 30 min prior to collecting the specimen.
      C)Ask the parents to leave the room prior to collecting the blood specimen.
      D)Demonstrate the use of the equipment to the child.
    3. A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching?
      A)"I should take this medication on an empty stomach."
      B)"I can continue to take St. John's wort while taking this medication."
      C)"I know it will be a couple of weeks before the medication helps me feel better."
      D)"I expect this medication to raise my blood pressure."
    4. A nurse is preparing a sterile field for a client who requires a dressing change. Which of the following actions should the nurse plan to take?
      A)Drop the sterile gauze from 25.4 cm (10 in) above the sterile field.
      B)Hold the sterile package in his dominant hand and open the top flap of the package toward his body.
      C)Place objects 1.27 cm (0.5 in) inside the border of the sterile field.
      D)Position the bottle outside the edge of the sterile field when pouring solution into a sterile container.
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