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    Exam Review

    1. Which is the primary goal when planning nursing care for a client with degenerative joint disease (DJD?
      A)Improve stress management skills.
      B)Achieve satisfactory pain control.
      C)Reduce risk for infection.
      D)Obtain adequate rest and sleep.
    2. The nurse is caring for an older adult client with a history of osteoarthritis who is having difficulty walking because of increased right knee pain. To assess the quality of the client's knee pain, which approach should the nurse use?
      A)Observe body language and movement.
      B)Identify effective pain relief measures.
      C)Provide a numeric pain scale.
      D)Ask the client to describe the pain.
    3. The health care provider prescribes a placebo instead of pain medication. Which intervention should the nurse implement?
      A)Administer the placebo as prescribed when the client reports pain.
      B)Tell the charge nurse about the prescribed placebo and refuse to administer it.
      C)Inform the client that the provider prescribed a placebo instead of pain medication.
      D)Discuss ethical concerns about placebo use with the healthcare provider.
    4. An older adult client arrives at the clinic describing a new onset of urinary incontinence. Which intervention should the nurse implement?
      A)Provide protective undergarments for the client.
      B)Encourage increased fluid intake for 24 hours.
      C)Evaluate the client's response to bladder training efforts.
      D)Obtain a clean, voided urine specimen for analysis.
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    Exam Review

    1. A client diagnosed with pancreatitis is reporting severe epigastric pain and intense nausea. After the nurse administers a narcotic analgesic and an antiemetic, the client insists on sitting up and leaning forward. Which action should the nurse implement?
      A)Reinforce bed rest until analgesic is effective.
      B)Place bed in reverse Trendelenburg position.
      C)Raise head of bed until at a 90-degree angle.
      D)Position bedside table for client to lean across.
    2. The nurse places an opioid patch on the chest of a client with intractable pain who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client?
      A)Elevate the head of the bed to a 45-degree angle.
      B)Remove dentures or other oral appliances.
      C)Lift and lock the side rails in place.
      D)Apply the client's positive airway pressure device.
    3. An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?
      A)Ask the client how often episodes of sundowning are experienced.
      B)Encourage the client to lie as still as possible during the assessment.
      C)Question the client about the frequency of falls in recent months.
      D)Assist the client with values clarification about end-of-life care options.
    4. An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?
      A)Question the client about the frequency of falls in recent months.
      B)Ask the client how often episodes of sundowning are experienced.
      C)Assist the client with values clarification about end-of-life care options.
      D)Encourage the client to lie as still as possible during the assessment.
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    Exam Review

    1. A client with type 1 diabetes mellitus (DM) is admitted in diabetic ketoacidosis. Treatment is initiated, and the nurse is preparing to administer IV fluids containing potassium chloride. Which assessment data is most important for the nurse to obtain before starting the infusion?
      A)Magnesium level.
      B)Size of the IV catheter.
      C)Urinary output of 30 to 60 mL/hr.
      D)Serum glucose level.
      E)None
      F)None
    2. The healthcare provider prescribes ear drops to an adult client with an ear infection. Which teaching should the nurse provide?
      A)Pull the pinnae up and back to administer the drops.
      B)Administer the drops with the head held upright.
      C)Cool and shake the bottle before administering the drops.
      D)Insert the tip of the dropper into the canal of the ear.
    3. The nurse is caring for an older adult client who is admitted to the surgical unit following a partial gastrectomy. In addition to frequent position changes, which postoperative intervention is most beneficial for the nurse to perform in preventing respiratory complications?
      A)Promote full diaphragmatic excursion by massaging the back.
      B)Note areas of atelectasis on the daily chest x-rays.
      C)Assist to a chair the day after surgery when the condition is stable.
      D)Provide ice or oral liquids when the client passes flatus.
    4. A client has a prescription for the insertion of a nasogastric tube to low intermittent suction. When inserting the nasogastric tube, the nurse observes an immediate return of "coffee ground" drainage. Which action should the nurse implement?
      A)Connect the nasogastric tube to high continuous suction.
      B)Clamp the nasogastric tube and contact the healthcare provider.
      C)Connect the nasogastric tube to suction as prescribed.
      D)Immediately remove and then reinsert the nasogastric tube.
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    Exam Review

    1. The nurse is caring for a client with a history of type 2 diabetes mellitus and hypertension who arrives at the clinic for a scheduled visit. Which finding requires further follow-up by the nurse? Creatinine: Female: [0.5 to 1.1 mg/dL (44 to 97 μmol/L)] Male: [0.6 to 1.2 mg/dL (53 to 106 μmol/L)]
      A)Difficulty staying asleep.
      B)Blood pressure 130/80 mm Hg.
      C)Dark yellow urine.
      D)Serum creatinine 1.6 mg/dL (141.44 μmol/L).
    2. The nurse is caring for a client with a binge eating disorder. Which goal should the nurse first establish with the client?
      A)Institute an exercise plan.
      B)Regulate food portions.
      C)Obtain satisfaction with appearance.
      D)Achieve a steady weight loss.
    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)Liquid brown drainage from stoma.
      B)Stomal output of 40 mL in the last hour.
      C)Red edematous stomal appearance.
      D)Mucous strings floating in the drainage.
    4. Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?
      A)Assist the client to recall everyone possibly exposed since the onset of symptoms.
      B)Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.
      C)Place the nasal swab specimen for COVID-19 directly into a biohazard bag.
      D)Move the client to a private room, keep the door closed, and initiate droplet precautions.
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    Exam Review

    1. A client with chronic obstructive lung disease who is receiving oxygen at 1.5 L/minute by nasal cannula, is currently short of breath. Which action should the nurse take?
      A)Have the client breathe into a paper bag.
      B)Ask the client to take short, rapid breaths.
      C)Instruct the client in pursed lip breathing.
      D)Increase oxygen to three L/minute.
    2. While removing staples from a client's postoperative wound site, the nurse observes that the client's eyes are closed and the client's face and hands are clenched. The client states, "I just hate having staples removed." After acknowledging the client's anxiety, which action should the nurse implement?
      A)Attempt to distract the client with general conversation.
      B)Explain the procedure in detail while removing the staples.
      C)Encourage the client to continue to verbalize the anxiety.
      D)Reassure the client that this is a simple nursing procedure.
    3. The parent of a child born with a myelomeningocele asks the nurse, "What did I do to deserve this?" Which response is most helpful?
      A)"This must be a very difficult time for you."
      B)"With surgery, your baby should have a full recovery."
      C)"Is there any particular reason why you think this is your fault?"
      D)"You didn't do anything wrong."
    4. The nurse administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, what laboratory value(s) should the nurse monitor? Select all that apply.(SATA)
      A)Blood urea nitrogen (BUN).
      B)White blood cell (WBC count.
      C)Red blood cell (RBC count.
      D)Urinalysis.
      E)Sputum culture and sensitivity.
      F)Serum potassium.
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    Exam Review

    1. Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?
      A)Assist the client to recall everyone possibly exposed since onset of symptoms.
      B)Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.
      C)Place the nasal swab specimen for COVID-19 directly into a biohazard bag.
      D)Move the client to a private room, keep the door closed, and initiate droplet precautions.
    2. A client with chronic obstructive lung disease who is receiving oxygen at 1.5 L/minute by nasal cannula is currently short of breath. Which action should the nurse take?
      A)Have the client breathe into a paper bag.
      B)Ask the client to take short, rapid breaths.
      C)Instruct the client in pursed lip breathing.
      D)Increase oxygen to three L/minute.
    3. While removing staples from a client's postoperative wound site, the nurse observes that the client's eyes are closed and the client's face and hands are clenched. The client states, "I just hate having staples removed." After acknowledging the client's anxiety, which action should the nurse implement?
      A)Attempt to distract the client with general conversation.
      B)Explain the procedure in detail while removing the staples.
      C)Encourage the client to continue to verbalize the anxiety.
      D)Reassure the client that this is a simple nursing procedure.
    4. A client with 50% full-thickness burns has received fluid resuscitation for the past 24 hours. Which assessment warrants immediate intervention by the nurse?
      A)Inspiratory and expiratory bilateral crackles.
      B)Average urine output of 28 mL/hour.
      C)Vesicular bibasilar breath sounds.
      D)Central venous pressure of 12 mm Hg.
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