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    Exam Review

    1. Exhibits The primary nurse reviews the client's history and vital signs. Select the 3 priority assessment findings that require immediate follow up.(SATA)
      A)Indigestion
      B)Tiredness
      C)Extremity pulse 2+
      D)Pain level in abdomen and back
      E)Pulsatile mass
      F)Liquid diarrhea
      G)Abdominal bruit
    2. Exhibits For each of the findings listed, click to indicate which are consistent with the disease process of aortic aneurysm versus gastric cancer. Each column must have at least one response option selected.
      Gastric cancerAortic aneurysm
      Auscultation of bruit✓
      Pulsatile mass✓
      Fatigue✓✓
      Indigestion✓
      Feeling of fullness✓
      Back pain✓
    3. Exhibits The nurse evaluates the client's findings and test results. Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. The nurse recognizes that the client is most at risk for aneurysm ▾ Rupture. The risk for this complication is highest in individuals with a history of▾ hypertension.
      Dropdown 1:
      Option 1: Rupture
      Option 2: Dissection
      Option 3: Occlusion
      Dropdown 2:
      Option 1: smoking
      Option 2: hypertension
      Option 3: hyperlipidemia
    4. Exhibits Nurse reviews updated chart data. For each intervention, click to indicate if it is indicated or contraindicated. Each row must have only one response option selected.
      IndicatedContraindicated
      Place client on 2 L/minute oxygen.✓
      Start 0.9% sodium chloride fluid bolus✓
      Ensure surgical consent has been completed.✓
      Insert indwelling urinary catheter.✓
      Document any skin lesions on lower legs.✓
      Mark pedal pulse sites with a single use marker.✓
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    Exam Review

    1. Exhibits After two days of intensive care, the client is transferred to the telemetry floor. The floor nurse is preparing a plan of care for the client. Which modifiable risk factor(s) should the nurse include in the teaching for this client? Select all that apply.(SATA)
      A)Family history
      B)Hypertension
      C)Obesity
      D)High cholesterol
      E)Age
      F)Male gender
      G)Coronary artery disease
      H)Tobacco use
    2. Exhibits The client is being considered for discharge to home where he will continue to recover. The nurse reassesses the client and evaluates him for discharge readiness. For each body system,
      (Highlight — findings requiring follow-up are marked)
      Exhibits

      The client is being considered for discharge to home where he will continue to recover. The nurse reassesses the client and evaluates him for discharge readiness.

      For each body system, click to specify the assessment finding(s) that would indicate the client is ready for discharge to home.

      Each body system may support more than one finding. Each category must have at least one response option selected.

       

      Body system

      Findings

      Cardiovascular

      Blood pressure of 120/74 mm Hg

      Capillary refill of 4 seconds in lower extremities

      Pedal pulse of 2+ or better

      Neurovascular

      Pupils equal and nonresponsive to light

      Absence of numbness or tingling in feet

      Skin that is pale, cool to touch

      Renal Perfusion

      Client has urine output of 1,600 mL in 24 hours

      Creatinine of 1.2 mg/dL (106 mmol/L)
    3. An adolescent with autism spectrum disorder (ASD) comes to the clinic for the first time. Which intervention(s) should the nurse implement? Select all that apply.(SATA)
      A)Consider having the teen's caregiver wait in the clinic reception area.
      B)Encourage the adolescent to handle the physical exam instruments.
      C)Allow time for talking before beginning the physical assessment.
      D)Familiarize the adolescent with the clinic setting and healthcare staff.
      E)Make every effort to establish eye contact with the adolescent.
    4. Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?
      A)Muscle pain.
      B)Diarrhea and flatulence.
      C)Abdominal cramps.
      D)Altered taste.
    Page 2 of 31

    Exam Review

    1. The nurse is assigned to care for two critical care clients. One client was admitted yesterday with pneumonia, is being mechanically ventilated and has an elevated temperature. The other client had a thoracotomy two days ago and is now complaining of incisional pain. Which intervention should the nurse implement first?
      A)Assess level of consciousness and vital signs for both clients.
      B)Administered pain medication to the client with incisional discomfort.
      C)Complete a head-to-toe physical assessment for the client with pneumonia.
      D)Review the plan of care and the medications for both clients.
    2. A client who weighs 110 lb receives a prescription for dalteparin 150 units/kg SUBQ daily for 4 months. The medication is available in 7,500 units/0.3 mL prefilled syringe. How many mL should the nurse administer? (Enter numerical value only.)
    3. Four days after exposure to COVID-19 a client has a negative COVID-19 test result. Eight days after the negative test result, the client presents with fever, fatigue, and cough and the nurse performs a second COVID-19 test. Which action is most important for the nurse to take?
      A)Report the COVID-19 result to the local health department according to the Center for Disease Control (CDC) guidelines.
      B)Isolate the client from other clients, family, and healthcare workers not wearing proper personal protective equipment (PPE).
      C)Notify the charge nurse the client will need assignment to the COVID-19 specified area of the facility.
      D)Place the nasal swab specimen for COVID-19 directly into a biohazard bag.
    4. The nurse administers ophthalmic timolol to a client with glaucoma. The client routinely takes carvedilol, spironolactone, and ibuprofen daily. Which medication(s) should the nurse withhold? Select all that apply.(SATA)
      A)Any antianxiety medications.
      B)Over-the-counter oral antipyretics.
      C)Nonsteroidal antiinflammatory drugs.
      D)Other beta-adrenergic blocker agents.
      E)Oral and subcutaneous anticoagulants.
    Page 3 of 31

    Exam Review

    1. The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse to report to the healthcare provide?
      A)Elevated liver function tests.
      B)Vomiting and diarrhea.
      C)Decreased white blood cell count.
      D)Pruritus and muscle aches.
    2. Exhibits The nurse evaluates the client findings. Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. The nurse evaluates the client and determines there are concerning symptoms, including subjective symptoms of ▾ sleeping difficulty and ▾ hypervigilance.
      Dropdown 1:
      Option 1: sleeping difficulty
      Option 2: withdrawn mood
      Option 3: alcohol on breath
      Option 4: blood pressure of 144/92 mmHg
      Dropdown 2:
      Option 1: hypervigilance
      Option 2: nightmares
      Option 3: latency of response
      Option 4: respirations of 20 breaths/minute
    3. Exhibits The nurse reviews the clinical findings. For each of the findings listed, click to indicate which are consistent with the disease process of major depressive disorder, generalized anxiety disorder, or posttraumatic stress disorder. Each column must have at least one response selected.
      Generalized anxiety disorderMajor depressive disorderPosttraumatic stress disorder
      Avoidance✓
      Suicidal ideation✓
      Nightmares✓
      Feelings of guilt✓✓
      Lack of interest✓
      Sleep disturbance✓✓✓
    4. Exhibits The nurse calms the client and deescalates the situation. The nurse notes that a diagnosis of posttraumatic stress disorder has been added to the care plan. Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. The nurse recognizes that elevated ▾ cortisol, epinephrine, and norepinephrine can cause increased alertness and ▾ hypervigilance.
      Dropdown 1:
      Option 1: acetylcholine, epinephrine, and norepinephrine
      Option 2: cortisol, epinephrine, and norepinephrine
      Option 3: dopamine, norepinephrine, and epinephrine
      Dropdown 2:
      Option 1: bradyphrenia
      Option 2: hypervigilance
      Option 3: hypoactivity
    Page 4 of 31

    Exam Review

    1. Exhibits The nurse receives the prescription for sertraline and prepares to give the medication. The nurse reviews the current medication prescription. Click to specify if the intervention is indicated or not indicated. Each row must have only one response selected.
      IndicatedNot Indicated
      Assess for pattern of bowel movements.✓
      Monitor suicidal ideation.✓
      Weigh client weekly.✓
      Offer frequent sips of fluids.✓
      Watch for hypotension.✓
    2. Exhibits The nurse evaluates the client and begins preparing for her discharge. Choose the most likely options for the information missing from the statements by selecting from the lists provided. The nurse teaches the client that it will take ▾ 4 to 8 weeks for the sertraline to reach full therapeutic effect and explains the client has been set up to receive ▾ eye movement desensitization and reprocessing as an outpatient. The nurse also teaches the client ▾ deep breathing to complement the medication and therapy.
      Dropdown 1:
      Option 1: 1 to 2 days
      Option 2: 4 to 8 weeks
      Option 3: 10 to 14 days
      Dropdown 2:
      Option 1: Cognitive behavioural therapy
      Option 2: Prolonged exposure therapy
      Option 3: eye movement desensitization
      Dropdown 3:
      Option 1: Progressive muscle relaxation
      Option 2: deep breathing
      Option 3: guided imagery
    3. A client with bladder cancer had surgical placement of a ureteroileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?
      A)Red edematous stomal appearance.
      B)Stomal output of 40 mL in last hour.
      C)Liquid brown drainage from stoma.
      D)Mucous strings floating in the drainage.
    4. A toddler is brought to the emergency department after ingesting several tablets of acetaminophen from a bottle that the toddler found in the mother's purse. The healthcare provider prescribes N-acetylcysteine solution for oral administration. Which action should the nurse implement if the child vomits?
      A)Teach parents about poison prevention in young children.
      B)Lavage activated charcoal before giving acetylcysteine dose.
      C)If dose is vomited within 1 hour of administration, repeat that oral dose.
      D)Obtain blood samples to monitor liver function.
    Page 5 of 31

    Exam Review

    1. An older adult with pneumonia and an exacerbation of chronic obstructive pulmonary disease (COPD) was intubated for 14 days and was sucessfully extubated yesterday. Currently, the client has a weak cough and poor appetite. Which intervention(s) should the nurse implement? Select all that apply.(SATA)
      A)Encourage activity as tolerated.
      B)Assess ability to swallow solids and liquids.
      C)Assist client with active range of motion.
      D)Reinforce deep breathing exercises.
      E)Obtain dietary consult for meal supplements.
    2. While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?
      A)Platelet count.
      B)Neutrophil count.
      C)Serum sodium level.
      D)Hematocrit.
    3. The first paddle has been placed on the chest of a client who needs defibrillation. Where should the nurse place the second paddle? (Mark the location where the second paddle should be placed on the image)
      Correct Answer:"{\"xRanges\":[68.3447994402985,73.94181436567165],\"yRanges\":[69.43765281173594,76.77261613691931]}"
    4. A female client with breast cancer is scheduled to receive a series of radiotherapy (RT). She has red hair, fair skin, and freckles. She tells the nurse that her skin is particularly sensitive to the sun, so she is worried that the radiation will adversely affect her skin. Which information should the nurse provide this client about RT? Select all that apply.(SATA)
      A)Both the sun and radiation can damage the skin because it has a rapid renewal rate.
      B)lonizing energy of RT penetrates to the target tumor and does not affect the skin like sun rays.
      C)Shielding helps to localize the entrance of RT and protects other sensitive areas.
      D)Special gels can be prescribed for local application to promote healing and comfort.
      E)Application of cold compresses after treatment decreases the skin's sensitivity.
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