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    Exam Review

    1. A nurse is assessing a client who is receiving treatment for psoriasis. Which of the following images depicts what the nurse should expect to observe?
      A ✓ Correct
      Option A
      B
      Option B
      A)A
      B)B
      C)C
      D)D
    2. A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)(SATA)
      A)"Empty the ostomy pouch when it becomes one-third full of contents."
      B)"Expect the stoma to turn a purple-blue color as it heals."
      C)"Cut the opening of the pouch of an inch larger than the stoma”
      D)"Place a piece of gauze over the stoma while changing the pouch.”
      E)"Use povidone-iodine to clean around the stoma”
    3. A nurse is caring for a client who has a chest tube with a closed drainage system. Which of the following actions should the nurse take?
      A)Milk the chest tube at least three times a day
      B)Empty the drainage collection chamber when full
      C)Ensure intermittent bubbling is present in the water seal chamber
      D)Clamp the chest tube when transferring the client from bed to the chair
    4. A nurse is caring for a client who is immobile. Which of the following interventions should the nurse plan to take to prevent plantar flexion contractures?
      A)Prop the feet up.
      B)Apply an abduction pillow to the legs.
      C)Use a trochanter roll.
      D)Use foot splints.
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    Exam Review

    1. A nurse is caring for an adult client who requires nasopharyngeal suctioning. Which of the following actions should the nurse take?
      A)Set the suction device to 120 mm Hg.
      B)Apply suction to the catheter during insertion.
      C)Have the client tuck his chin to his chest during suctioning.
      D)Apply a petroleum-based lubricant to the catheter.
    2. A nurse is preparing to remove an indwelling urinary catheter from a client. In what order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
      A)Slowly pull the catheter out of urethral canal.4
      B)Don clean gloves.1
      C)Withdraw the solution from the balloon.3
      D)Dry the perineal area.5
      E)Attach the syringe to the balloon injection port.2
    3. A nurse is planning care for a client who has contact precautions in place. Which of the following actions should the nurse plan to take when removing soiled linens from the client's room?
      A)Double-bag the linens.
      B)Rinse the linens prior to removing them from the client's room.
      C)Tie the linens' bag securely at the top.
      D)Wear sterile gloves when handling the linens.
    4. A nurse is preparing to administer a medication to a client for the first time. Which of the following actions should the nurse take to help ensure safe medication administration?
      A)Read the medication label twice prior to administration.
      B)Ask the client if they have ever taken a similar medication.
      C)Use one patient identifier prior to medication administration.
      D)Access the online drug formulary for an unfamiliar medication.
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    Exam Review

    1. A nurse in a postpartum clinic is caring for a client who has returned for their 6-week postpartum visit. The client states emphatically, "I hate when the baby cries, and I can't get them to stop." Which of the following statements should the nurse respond with?
      A)"You should try putting the baby in a carrier so you can take a walk when they start crying.”
      B)"Tell me more about what is going on when the baby starts crying.”
      C)"Many parents have told me it gets better when the baby is about 3 months old.”
      D)"As a new parent, you should be enjoying your time with the baby.”
    2. A nurse is caring for a client who was administered more than the prescribed dose of a medication. Which of the following actions should the nurse take first?
      A)Notify the primary care provider.
      B)Obtain the client's vital signs.
      C)Educate the client about potential adverse effects.
      D)Complete an incident report.
    3. A nurse is caring for a client who has hypocalcemia. Which of the following findings should the nurse expect?
      A)Muscle flaccidity
      B)Lethargy
      C)Constipation
      D)Positive Chvostek's sign
    4. A nurse is caring for a client on a medical-surgical unit. Which of the following actions should the nurse take to maintain the client's confidentiality?
      A)Discuss the client's condition with a nurse on another unit.
      B)Fax client information with a cover sheet.
      C)List the client's name and condition on board at the nurses’ station.
      D)Post client diagnosis on message board in their room.
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    Exam Review

    1. A nurse is caring for a client who has just died following unsuccessful CPR. The family wishes to view the body. Which of the following actions should the nurse take before inviting the family into the room?
      A)Leave resuscitation equipment and supplies at the bedside.
      B)Hold the client's eyelids closed until they remain shut.
      C)Apply identification tags to the client's extremities.
      D)Keep the head of the bed flat.
    2. A nurse is evaluating a newly licensed nurse's understanding of advance directives. The newly licensed nurse should identify that which of the following individuals is responsible for deciding whether a client is capable of making their own decisions regarding medical treatment?
      A)Primary provider
      B)Charge nurse
      C)Health care surrogate
      D)Social worker
    3. A nurse is assessing a client's sleep-wake patterns during an initial clinic visit. Which of the following findings should the nurse report to the provider?
      A)The client reports frequently having a headache in the morning.
      B)The client reports having vivid dreams about their childhood.
      C)The client reports taking 30 min to fall asleep on average.
      D)The client reports sleeping about 7 hr on average.
    4. A nurse is discussing expected changes associated with aging with an older adult client. Which of the following client statements should indicate to the nurse that the client has an impaired body image?
      A)"My hearing has improved since I got my hearing aids.”
      B)"My wrinkled hands show how hard I've worked all my life.”
      C)"I avoid going out because I sometimes have problems with incontinence.”
      D)"These lines in my face reveal a part of my character."
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    Exam Review

    1. A nurse is providing a handoff report to the oncoming shift nurse. Which of the following actions should the nurse take to ensure continuity of client care?
      A)Use a standardized approach to giving the handoff report.
      B)Encourage the oncoming shift nurse to contact the provider with any questions.
      C)Provide the handoff report at the nurses' station
      D)Record a verbal report on a recorder for the oncoming nurse to listen to
    2. A nurse is planning care for a client who has urinary incontinence. Which of the following interventions should the nurse include in the client's plan of care?
      A)Apply a moisture barrier ointment to the area in contact with urine.
      B)Assist with toileting every 4 hr while awake.
      C)Instruct the client to consume fluids between 0600 and 2200.
      D)Cleanse the skin with antibacterial soap and hot water after each incontinence episode.
    3. A nurse in an outpatient clinic is caring for a client. Which of the following findings indicates the client is experiencing a hearing deficit?
      A)Persistent repositioning of objects
      B)No response to tactile stimuli
      C)Decreased attention span
      D)Presence of expressive aphasia
    4. A nurse is teaching a client about meditation and progressive relaxation to reduce stress. Which of the following instructions should the nurse include?
      A)Keep eyes open during relaxation therapy.
      B)Tighten and relax muscles during relaxation therapy.
      C)Plan to meditate immediately after meals.
      D)Take short and shallow breaths when meditating
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    Exam Review

    1. A nurse is observing a client who is in four-point restraints for violent and self-destructive behavior. Which of the following actions should the nurse take when using four-point restraints?
      A)Assess the client every hr for circulation, possible injury, and readiness for discontinuation.
      B)Check the client's peripheral pulses and skin integrity every 15 min.
      C)Assist the client with passive range of motion exercises every 3 hr.
      D)Attach the extremity restraint straps to the bed rails using a quick-release buckle.
    2. A nurse is assessing a client who has a history of violent behaviors. Which of the following manifestations should the nurse recognize as a risk for violent behaviors?
      A)Silence
      B)Pacing
      C)Lack of eye contact
      D)Lowered tone of voice
    3. A nurse overhears two staff members in the facility elevator discussing a client's care. Which of the following federal statutes does this violate?
      A)Patient Protection and Affordable Care Act
      B)American With Disabilities Act
      C)Patient Self-Determination Act
      D)Health Insurance Portability and Accountability Act
    4. A nurse is caring for a client who states, "I smoke because I have a lot of anxiety." The nurse should recognize the client's statement as which of the following defense mechanisms?
      A)Projection
      B)Sublimination
      C)Rationalization
      D)Dissociation
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