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    Exam Review

    1. A client with a history of heart failure arrives at the emergency department describing an onset of fatigue and weakness. The client has been taking spironolactone 50 mg tablets PO every day. The nurse receives report from the lab that the client has a serum potassium level of 6.2 mEq/L (6.2 mmol/L). Which intervention is most important for the nurse to implement?
      A)Compare muscle strength bilaterally.
      B)Determine apical pulse rate and rhythm.
      C)Assess strength of deep tendon reflexes.
      D)Observe color and amount of urine.
    2. In formulating the nursing care plan for a client diagnosed with Parkinson's disease, which nursing problem has the highest priority?
      A)Self-care deficit relative to motor disturbance.
      B)Risk for aspiration relative to muscle weakness.
      C)Risk for constipation relative to immobility.
      D)Impaired physical mobility relative to muscle rigidity.
    3. The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the CLIENT?
      A)For the next 24 hours, notify the nurse when the bladder is full, and the nurse will collect catheterized specimens.
      B)Urinate immediately into a urinal, and the lab will collect the specimen every 6 hours for the next 24 hours.
      C)Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours.
      D)Cleanse and meatus, discard the first portion of voiding, and collect the rest in a sterile bottle.
    4. A client experiencing withdrawal from the benzodiazepine alprazolam is demonstrating severe agitation and tremors. Which is the best initial nursing action?
      A)Instruct the family about withdrawal symptoms.
      B)Initiate seizure precautions.
      C)Obtain a serum drug screen.
      D)Administer naloxone per PRN protocol.
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    Exam Review

    1. A client is brought to the emergency department after falling from of a ladder and is showing signs of confusion and disorientation. The spouse states the client appeared to have lost consciousness. The nurse is provided with a list of current medications and healthcare power of attorney. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?
      A)Currently prescribed medications.
      B)Falling from a ladder as reason for admission.
      C)Increasing confusion of the client.
      D)Client's healthcare power of attorney.
    2. A client with pancreatic cancer develops ascites, and 2 liters of fluid are removed via paracentesis. Which schedule should the nurse implement to assess the client's blood pressure after this procedure?
      A)Every 5 minutes for 30 minutes, then every 4 hours thereafter.
      B)Every 5 minutes for one hour.
      C)Every 15 minutes for one hour, then every 1 hour for 2 hours.
      D)Every 1 hour for 2 hours.
    3. The nurse is teaching a primigravida about preeclampsia. What finding(s) are indicators of preeclampsia and should be reported to the healthcare provider? Select all that apply.(SATA)
      A)Swollen hands.
      B)Headache.
      C)Blurred vision.
      D)Lack of appetite.
      E)Chills and fever.
      F)Urinary frequency.
    4. The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond?
      A)Provide a list of alternative activities that are less likely to cause the child to experience fatigue.
      B)Suggest that the child be encouraged to participate in a team sport to encourage socialization.
      C)Explain that their child is too young to understand the risks associated with swimming.
      D)Encourage the parents to allow the child to continue attending swimming lessons with supervision.
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    Exam Review

    1. Restricted activity is prescribed for a client with Crohn's disease. The nurse should explain that the primary purpose of the activity restriction is to obtain which outcome?
      A)Promote healing process.
      B)Decrease abdominal pain.
      C)Reduce intestinal activity.
      D)Control diarrhea episodes.
      E)None
      F)None
    2. The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. Which action should the nurse include?
      A)Apply a water-soluble lubricant to the catheter.
      B)Wear protective goggles while performing the procedure.
      C)Instill 3 mL of normal saline before suctioning.
      D)Instruct the client to cough as the suction tip is removed.
    3. A postpartum client who is bottle-feeding develops breast engorgement. Which is the best recommendation for the nurse to provide this client?
      A)Avoid stimulation of the breasts and wear a tight bra.
      B)Express a small amount of breast milk by hand.
      C)Place warm packs on both breasts.
      D)Take a prescribed analgesic and expose breasts to air.
      E)None
      F)None
    4. To auscultate for a carotid bruit, the nurse places the stethoscope at what location (Select the correct location on the image. To change, click on a new location.)
      A ✓ Correct
      Option A
      A)A
      B)B
      C)C
      D)D
    Page 3 of 30

    Exam Review

    1. The nurse is caring for a client who reports sudden right-sided numbness and weakness of the arm and leg. The nurse also observes a distinct right-sided facial droop. After reporting the findings to the healthcare provider, the nurse receives several prescriptions for the client, including a STAT computerized tomography scan of the head. Which action should the nurse take first?
      A)Administer aspirin to prevent further clot formation and platelet clumping.
      B)Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment.
      C)Begin continuous observation for transient episodes of neurologic dysfunction.
      D)Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.
    2. After receiving report, the nurse can most safely plan to assess which client last?
      A)An adult client with no postoperative drainage in the Jackson-Pratt drain with the bulb compressed.
      B)An adult client with a rectal tube draining clear, pale red liquid drainage.
      C)An older client with a distended abdomen and no drainage from the nasogastric tube.
      D)An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac.
    3. Oxygen at 5 L/minute per nasal cannula is being administered to a 10-year-old child with pneumonia. When planning care for this child, which principle of oxygen administration should the nurse consider?
      A)Oxygen is less toxic when it is humidified with a hydration source.
      B)Avoid administration of oxygen at high levels for extended periods.
      C)Increase oxygen rate during sleep to compensate for slower respiratory rate.
      D)Taking a sedative at bedtime slows respiratory rate, which decreases oxygen needs.
    4. The primary caregiver of an older adult client calls the nurse at the outpatient clinic due to a sudden onset of changes in the client's behavior. The caregiver reports to the nurse that the client normally is oriented and able to answer questions but now is confused and agitated. What action(s) should the nurse take? Select all that apply.(SATA)
      A)Ask if the client is experiencing any pain with urination.
      B)Determine if the client has recently experienced a fall.
      C)Provide instruction on taking the client's temperature.
      D)Encourage increased intake of high protein foods.
      E)Review the client's current food and medication allergies
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    Exam Review

    1. The nurse identifies an electrolyte imbalance, an elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with hepatic failure. Which intervention should the nurse include in the plan of care?
      A)Provide only distilled water.
      B)Document abdominal girth.
      C)Offer a high protein diet.
      D)Use a cushion when sitting.
    2. A primigravida client at 36-weeks gestation is admitted to the labor and delivery unit because her membranes ruptured 30 minutes ago. Initial assessment indicates a 2 cm cervical dilatation, 50% effaced, -2 station, vertex presentation, greenish-colored amniotic fluid, and contractions occurring every 3 to 5 minutes, with a decrease in fetal heart rate after the last four contraction peaks. Which action should the nurse implement first?
      A)Administer oxygen via face mask.
      B)Apply an Internal fetal heart monitor.
      C)Notify the healthcare provider.
      D)Use a vibroacoustic stimulator.
    3. A school-aged client was recently diagnosed with type 1 diabetes mellitus. Which symptom did the client's parents most likely report?
      A)Gained 10 lb (4.5 kg) within one month.
      B)Drinks more fluids than previously.
      C)Voids only one or two times per day.
      D)Refuses to eat favorite meals at home.
    4. An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasm when taking the blood pressure using the same arm. After confirming the presence of the spasms, which action should the nurse take?
      A)Tell the UAP to use a different sphygmomanometer.
      B)Ask the UAP to take the blood pressure in the other arm.
      C)Administer a PRN antianxiety medication.
      D)Review the client's serum calcium level.
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    Exam Review

    1. The nurse is assigned to care for a client diagnosed with psoriasis. Which behavior by the nurse addresses this client's psychosocial need for acceptance?
      A)Wearing gloves when interviewing the client.
      B)Allowing the client to ventilate feelings.
      C)Encouraging the client to join a support group.
      D)Shaking the client's hand during an introduction.
    2. A client who is hypotensive is receiving dopamine, an adrenergic agonist, intravenously (IV) at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?
      A)Measure urinary output every hour.
      B)Initiate seizure precautions.
      C)Assess pupillary response to light hourly.
      D)Monitor serum potassium frequently.
    3. A male adult is admitted because of an acetaminophen overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan?
      A)Do not take any over-the-counter medications.
      B)Eat a high carbohydrate, low fat, low protein diet.
      C)Call the crisis hot line if feeling lonely.
      D)Avoid exposure to large crowds.
    4. A client is currently receiving an infusion labeled Heparin Sodium 25,000 Units in 5% Dextrose Injection 500 mL at 14 ml/hour. A prescription is received to change the rate of the Infusion to 900 units of heparin per hour. The nurse should set the infusion pump to deliver how many mL/hour? (Enter numeric value only.)
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