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    Exam Review

    1. A nurse is caring for a client in an outpatient clinic Exhibits Select the 2 findings the nurse should identify as factors that may interfere with the client's sleep(SATA)
      A)Bedtime
      B)Use of chronic devices
      C)Evening meal
      D)Medication
      E)Caffeine use
      F)Exercise schedule
    2. A nurse is caring for a school-age child who has celiac disease. Which of the following food choices should the nurse incorporate into the child's diet?
      A)Rye bread
      B)Whole wheat pretzels
      C)Graham crackers
      D)Wild rice
    3. A nurse is caring for a client who has lactose intolerance and eliminated dairy products from their diet. The nurse should instruct the client to increase consumption of which of the following foods?
      A)Ground beef
      B)Peanut butter
      C)Kale
      D)Canoes
    4. A nurse is caring for a dent in a cardiology clinic. Complete the following sentence by using the lists of options. Based on the client data, the nurse should identify the client is experiencing ▾ heart failure as evidenced by ▾ heart and lung sounds.
      Dropdown 1:
      Option 1: heart failure
      Option 2: urinary tract infection
      Option 3: fluid volume deficit
      Option 4: atrial fibrilation
      Dropdown 2:
      Option 1: 12-lead ECG findings
      Option 2: urinary report
      Option 3: heart and lung sounds
      Option 4: blood pressure
    Page 1 of 45

    Exam Review

    1. During the immediate postoperative period following thoracic surgery, a nurse medicates a client for pain on a schedule. The rationale for this nursing action is which of the following?
      A)Suppresses the cough reflex
      B)Decreases the level of anxiety
      C)Reduces the respiratory
      D)Facilitates deep breathing
    2. A nurse is caring for a client who has fractured ribs, has developed thrombophlebitis, and is being treated with a heparin drip. The client develops hematuria and has an activated partial thromboplastin time (aPTT) of 100 seconds (60 to 80 seconds). Which of the following actions should the nurse take first?
      A)Turn off the heparin drip
      B)Administer protamine sulfate
      C)Repeat the aPTT now and in 1 hr
      D)Obtain a portable chest x-ray
    3. A nurse is caring for a 6-year-old child in an emergency department. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
      ✓Assess for neurological changes.
      ✓Plan to administer high dose of aspirin
      ✓Kawasaki disease
      ✓Reports of chest pain or pressure
      ✓Daily weights
      Actions to Take Choices
      ✕Restrict fluid and salt intake
      ✓Assess for neurological changes.
      ✓Plan to administer high dose of aspirin
      ✕Provide soft food
      ✕Implement airbone precautions
      Potential Condition Choices
      ✕Reyes syndrome
      ✕Varicella
      ✓Kawasaki disease
      ✕Rheumatic fever
      Parameters to measure Choices
      ✕Prolonged bleeding time
      ✓Reports of chest pain or pressure
      ✓Daily weights
      ✕Lesion bruising
      ✕Chorea
    4. A nurse is caring for a client on the medical surgical unit Which of the following client findings suggest that the nurse should hold the tube feeding and notify the provider?(SATA)
      A)Gastric content pH
      B)Abdominal findings
      C)Oxygen saturation
      D)Gastric residual
      E)Blood glucose
      F)Laboratory electrolyte levels
    Page 2 of 45

    Exam Review

    1. A nurse is preparing to administer lactulose 30 g PO four times daily to a client who has portal-systemic encephalopathy. The amount available is lactulose al solution 10 g/15 ml. How many ml. should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)
    2. A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN?
      A)insert an indwelling catheter if the client has not voided in 3hr
      B)Obtain the abdominal girth now and every 4 hr.
      C)Assess and document the level of consciousness every hour.
      D)Measure the amount of gastric drainage every 2 hrs
    3. A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel?
      A)Provide discharge instructions.
      B)Perform chest compressions during cardiac resuscitation
      C)Perform a dressing change for a new amputee
      D)Assess effectiveness of antiemetic medication
    4. A nurse is caring for a client who is at 20 weeks of gestation Which of the following actions should the nurse plan to take? Select all that apply.(SATA)
      A)Apply internal fetal monitor.
      B)Prepare client for dilation and curettage with suction
      C)Administer 1 hr glucose tolerance test
      D)Refer client to perinatal loss support group
      E)Provide the client with instructions on medroxyprogesterone therapy.
      F)Administer Rho (D) immune globulin
    Page 3 of 45

    Exam Review

    1. A nurse is assessing a client's cardiovascular system. Identify where the nurse should place the diaphragm of the stethoscope to best hear the closing of the aortic heart valve. (You will find "Hot Spots" to select in the artwork below. Select only the hotspot that corresponds to your answer.)
      Correct Answer:"{\"xRanges\":[30.940896739130434,33.33220108695652],\"yRanges\":[36.748633879781416,39.75409836065574]}"
    2. A nurse is caring for a client who is on the cardiac step-down unit. Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing ▾ Stroke as evidenced by their ▾ Cardiac rhythm
      Dropdown 1:
      Option 1: Atelectasis
      Option 2: Stroke
      Option 3: Cardiac tamponade
      Option 4: Pneumothorax
      Option 5: Infection
      Dropdown 2:
      Option 1: Cardiac rhythm
      Option 2: Chest tube assessment
      Option 3: Lung sounds
      Option 4: Heart sounds
      Option 5: Dressing assessment
    3. A nurse is caring for a client. Exhibits Which of the following actions should the nurse expect to take? Select all that apply.(SATA)
      A)Administer diphenhydramine 50 mg IM.
      B)Arrange for transport of the client to the nearest emergency department
      C)Apply cool, wet washcloths to the client's forehead and axilla.
      D)Administer fluphenazine decanoate in the client's deltoid.
      E)Instruct the client to discontinue risperidone
    4. A nurse is caring for a client who reports the use of chondroitin and glucosamine. The health benefit of this supplement combination is to do which of the following?
      A)Treat mild to moderate depression
      B)Enhance the immune system.
      C)Prevent and treat prostate enlargement
      D)Improve joint functioning
    Page 4 of 45

    Exam Review

    1. A nurse is caring for a child in the emergency department. Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is most at risk for developing ▾ Peritonitis due to ▾ Perforated appendix
      Dropdown 1:
      Option 1: Pneumonia
      Option 2: Dehydration
      Option 3: Ileus
      Option 4: Anxiety
      Option 5: Peritonitis
      Dropdown 2:
      Option 1: Client statement
      Option 2: Bowel sounds
      Option 3: Perforated appendix
      Option 4: Lung sounds
      Option 5: Nausea and vomiting
    2. A nurse is planning care for a client who has a deep vein thrombosis in the right leg. Which is the following actions should the nurse include in the plan?
      A)Maintain client on bed rest
      B)Elevate the client's affected extremity.
      C)Apply cold compresses to the client's affected extremity
      D)Massage the muscle of the client's affected extremity
    3. A nurse is caring for a preschool-age child who has a short-leg plaster cast applied 1 hr ago. Which of the following is an appropriate intervention
      A)Restrict movement of the toes of the affected leg
      B)Dry the cast with a hair dryer set on a warm setting
      C)Reposition the affected leg using fingertips
      D)Support the affected leg on a pillow
    4. A nurse is caring for a 7-year-old child who has severe dehydration. Which of the following findings should the nurse expect?
      A)Blood pressure 94/68 mm Hg
      B)Urinary output 30 mL/hr
      C)Respiratory rate 24/mn
      D)Heart rate 152/min
    Page 5 of 45

    Exam Review

    1. A nurse is teaching the parent of an infant about the manifestations of food allergies. The nurse should identify which of the following findings as a common manifestation of a food allergy?
      A)Vomiting
      B)Dry mouth
      C)Decreased respiratory rate
      D)Hypertension
    2. A client who is having suicidal thoughts tells the nurse, it just does not seem worth it anymore. Why not end my misery?" Which of the following responses by the nurse is appropriate?
      A)"Why do you think your life is not worth it anymore?”
      B)"You can trust me and tell me what you are thinking”
      C)"I need to know what you mean by misery”
      D)“Do you have a plan to end your life?”
    3. A nurse is caring for a client who is receiving continuous feedings via NG tube. Which of the following actions should the nurse take?
      A)Irrigate the client's tube with 10 ml of cool water every hr
      B)Elevate the head of the client's bed to a 15 angle
      C)Replace the client's feeding bag every 72 hr
      D)Check the client's gastric residual every 4 hr.
    4. A nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy with clozapine. Which of the following is the highest priority for the client to report to the provider?
      A)Blurred vision
      B)Dry mouth
      C)Fever
      D)Constipation
    Page 6 of 45