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    Exam Review

    1. A nurse is caring for a client who is postoperative following administration of general anesthesia. Exhibits Select 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.
      ✓Administer dantrolene
      ✓Monitor muscle rigidity
      ✓Malignant hyperthermia
      ✓Bowel sounds
      ✓Muscle rigidity
      Actions to Take
      ✕Obtain the latex-free cart
      ✕Administer ondansetron
      ✓Administer dantrolene
      ✕Insert a nasogastric (NG) tube
      ✓Monitor muscle rigidity
      Condition Most Likely Experiencing
      ✕Paralytic ileus
      ✕Nausea and vomiting
      ✕Hypercapnia
      ✓Malignant hyperthermia
      ✕Latex allergy
      Parameters to Monitor
      ✕Blood pressure
      ✕Urine output
      ✓Bowel sounds
      ✕Skin integrity
      ✓Muscle rigidity
    2. Patient Data Exhibits Select the 4 assessment findings that require immediate follow up.(SATA)
      A)Severe abdominal pain in right lower quadrant
      B)Blood pressure 115/76 mm Hg
      C)Capillary refill 2 seconds
      D)Radial and pedal pulses 2+1
      E)Temperature 100.8° F (38.2° C)
      F)Respirations 28 breaths/minute with shallow breathing
      G)Feels anxious
      H)Heart rate 121 beats/minute
      I)Vomiting small amounts of green bile
    3. Exhibits The healthcare provider places orders to determine the cause of client symptoms. Use the chart to indicate if the listed symptom or finding is consistent with gastroenteritis, appendicitis, or ectopic pregnancy. Each row must have at least one, but may have more than one, response option selected.
      AppendicitisEctopic pregnancyGastroenteritis
      Fever✓✓
      Tachycardia✓✓✓
      Nausea✓✓✓
      Vomiting✓✓✓
      Diarrhea✓
    4. Exhibits Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. The nurse recognizes that the client has ▾ Appendicitisas evidenced by ▾ white blood cell count (WBC)and▾ computed tomography (CT) scan results.
      Dropdown 1:
      Option 1: Appendicitis
      Option 2: Gastroenteritis
      Option 3: Pneumonia
      Dropdown 2:
      Option 1: white blood cell count (WBC)
      Option 2: Bowel movement
      Option 3: Respiratory system findings
      Option 4: Respiratory rate
      Option 5: Blood pressure
      Dropdown 3:
      Option 1: Respiratory rate
      Option 2: Bowel movement
      Option 3: Respiratory system findings
      Option 4: computed tomography (CT) scan results
      Option 5: Blood pressure
    Page 1 of 32

    Exam Review

    1. Exhibits The nurse is stabilizing the client and preparing her for surgery. What goal(s) should the nurse prioritize in the care plan for the client while in the emergency department? Select all that apply.(SATA)
      A)Effective coping with illness related anxiety
      B)Infection prevention related to illness
      C)Relief of acute pain
      D)A review of diet progression postoperatively
      E)Promotion of bowel routine
      F)Prevention of deep vein thrombosis (DVT) related to immobility
      G)Fluid volume management
      H)Client education about diagnosis and plan of care
    2. Exhibits The nurse is caring for the client the morning after her surgery. Click to select the 5 most important nursing interventions for postoperative client care.(SATA)
      A)Encourage sitting up and ambulation
      B)Monitor for bleeding once daily
      C)Use Incentive spirometer every 1 hour
      D)Promote adequate hydration
      E)Assess for sedation after pain medications
      F)Complete neurologic assessment every 2 hours
      G)Administer pain medication after activity
    3. Exhibits The client has recovered from surgery and is ready to be discharged. Highlight findings that indicate the client is stable and ready to be discharged. The client returned from appendectomy surgery last night at approximately 2100. The client was admitted for observation due to a delay in waking from anesthesia. The client is currently resting in bed. The incision dressing is dry and intact, and no bleeding is noted. The client tolerated clear liquids post recovery and has advanced to a soft diet. The client ambulated around the unit this morning and tolerated activity well. Bowel sounds are present in all 4 quadrants, and per client report, she has passed flatus. Pain is tolerated with analgesia PO.
      (Highlight — findings requiring follow-up are marked)
      Exhibits

      The client has recovered from surgery and is ready to be discharged.

      Highlight findings that indicate the client is stable and ready to be discharged.

      The client returned from appendectomy surgery last night at approximately 2100. The client was admitted for observation due to a delay in waking from anesthesia. The client is currently resting in bed. The incision dressing is dry and intact, and no bleeding is noted. The client tolerated clear liquids post recovery and has advanced to a soft diet. The client ambulated around the unit this morning and tolerated activity well. Bowel sounds are present in all 4 quadrants, and per client report, she has passed flatus. Pain is tolerated with analgesia PO.

    4. When providing client care, the nurse identifies a problem and develops a related clinical question. Next, the nurse intends to gather evidence so that the decision-making process in response to the problem and clinical question is evidence-based. When gathering evidence, which consideration is most important?
      A)Frequency that the problem occurs.
      B)Relevance to the situation.
      C)Past experience with similar problems.
      D)Related personal values.
    Page 2 of 32

    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 (HCP), the nurse receives several prescriptions for the client, including a STAT computerized tomography (CT) scan of the head. Which intervention should the nurse perform in the immediate management of the client?
      A)Obtain a focused history to determine recent bleeding and use of anticoagulants.
      B)Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment.
      C)Initiate bilateral intermittent sequential pneumatic compression devices.
      D)Maintain elevated positioning of the dependent joints on affected side.
    2. A client with a permanent pacemaker has no pulse or spontaneous respirations and the monitor is displaying a ventricular fibrillation rhythm. Resuscitation is in progress and the nurse is preparing to defibrillate the client with 200 joules of unsynchronized defibrillation. Which intervention is most important for the nurse to implement?
      A)Obtain 12-lead electrocardiogram to evaluate return of pacemaker's sensing, firing, and capture.
      B)Ensure permanent pacemaker interrogated if return of spontaneous circulation is achieved.
      C)Place self-adhesive defibrillator pads at least 1 inch away from permanent pacemaker site.
      D)Apply a doughnut magnet over the pacemaker if pacer-mediated tachycardia develops.
    3. The psychiatric nurse is talking to a newly admitted client when another male client, who is diagnosed with antisocial behavior, intrudes on the conversation and tells the nurse, "I have to talk to you right now! It is very important!" How should the nurse respond to this client?
      A)Encourage him to go to the nurse's station and talk with another nurse.
      B)Put his behavior on extinction (do not acknowledge it) and continue talking with the newly admitted client.
      C)Inform him that the nurse is busy admitting a new client and will talk to him later.
      D)Introduce him to the newly admitted client and ask him to join in the conversation.
    4. The nurse observes an unlicensed assistive personal (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?
      A)Holding hands below elbows when rinsing.
      B)Washing for a total of 20 seconds.
      C)Turning the water off using bare hands.
      D)Lathering using a circular movement.
    Page 3 of 32

    Exam Review

    1. The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?
      A)An older client with scabies who is admitted from an extended care facility.
      B)A client with a positive Mantoux and sputum cultures results positive for acid-fast bacillus (AFB).
      C)A female adolescent admitted with multiple genital Herpes simplex II lesions.
      D)Twin siblings admitted with scarlet fever that is complicated with pneumonia.
    2. The nurse is caring for a client who reports running out of aspirin 1 week ago and taking ibuprofen as a replacement. Which information should the nurse obtain from the client first?
      A)Amount of pain control.
      B)Presence of gastric pain.
      C)Reason for taking the aspirin,
      D)Dosage of ibuprofen taken.
    3. A client with pancreatitis reports severe epigastric pain, so the nurse administers a prescribed narcotic analgesic Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement?
      A)Position bedside table so the client can lean across it.
      B)Raise head of bed until to a 90 degree angle.
      C)Encourage rest until the analgesic becomes effective.
      D)Place bed in a reverse trendelenburg position.
    4. Patient Data Exhibits Which should the nurse immediately do? Select all that apply.(SATA)
      A)Notify the surgeon
      B)Place the client in low-Fowler's with knees raised
      C)Start a peripheral IV (PIV)
      D)Cover the wound with moistened sterile gauze
      E)Hold pressure on the dressing
      F)Encourage the client to drink fluids
      G)Assist the client to cough and deep breathe
    Page 4 of 32

    Exam Review

    1. Review H and P and nurses’ notes. Exhibits
      (Highlight — findings requiring follow-up are marked)

      Review H and P and nurses’ notes.

      Exhibits

      Click to highlight which assessment findings should the nurse attend to right away?

      Admitted client. Vital signs: heart rate 128 beats/minute, rhythm sinus tachycardia, respiratory rate 14 breaths/minute, oxygen saturation 100% on 40% fraction of inspired oxygen, temperature 96.9° F (36.1° C), blood pressure 90/79 mm Hg. Pulse pressure calculated to be less than 40 mm Hg. The client's surgical dressing is clean and dry. Ecchymosis noted on the abdomen around the dressing. The client has a peripheral intravenous line in the right forearm and one in the left hand. The client also has a right subclavian central venous catheter that is infusing propofol and intravenous fluids.

    2. A client with osteomyelitis from a compound fracture of the left tibia has an open draining wound and is admitted with possible methicillin- resistant Staphylococcus aureus (MRSA) infection. Which interventions should the nurse include in the plan of care? Select all that apply.(SATA)
      A)Monitor the client's white blood cell count.
      B)Institute contact precautions for staff and visitors.
      C)Send wound drainage for culture and sensitivity.
      D)Explain the purpose of a low bacteria diet.
      E)Use standard precautions and wear a mask.
    3. The nurse is preparing to administer a formula feeding by nasogastric tube (NGT) to a 2-month-old. Which intervention should the nurse implement?
      A)Measure and discard residual gastric contents before feeding.
      B)Use the syringe plunger to push formula at a rate of 5 mL/minute.
      C)Hold the infant with head and shoulders slightly elevated.
      D)Microwave refrigerated formula to room temperature.
    4. While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?
      A)Sodium intake with meals and snacks affects the blood pressure.
      B)Elevated blood pressure must be anticipated and identified quickly.
      C)Blood pressure fluctuations means that the condition has become chronic.
      D)Hypotension leading to sudden shock can develop at any time.
    Page 5 of 32

    Exam Review

    1. The nurse knows that a medication has the side effect of orthostatic hypotension. Which assessment should the nurse make before administering the medication?
      A)Blood pressure.
      B)Apical heart Fate.
      C)Pulse pressure.
      D)Level of consciousness.
    2. Following a gunshot wound, an adult client has a hemoglobin level of 4 g/dL (40 g/L). The nurse prepares to administer a unit of blood for an emergency transfusion. The client has AB negative blood type and the blood bank sends a unit of Type A Rh negative, reporting that there is no Type AB negative blood currently available. Which intervention should the nurse implement? Reference Range Hemoglobin [14 to 18 g/dL (140 to 180 g/L)
      A)Obtain additional consent for administration of Type A negative blood.
      B)Recheck the client's hemoglobin, blood type, and Rh factor.
      C)Transfuse Type A negative blood until Type AB negative is available.
      D)Administer normal saline solution until Type AB negative is available.
    3. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Vital signs include a heart rate of 122 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 170/90 mm Hg. Which assessment finding warrants the most immediate intervention by the nurse?
      A)Yellow expectorated sputum
      B)Shortness of breath on exertion.
      C)Oral temperature of 100.5 F (38.1°C).
      D)Bilateral diffuse wheezing.
    4. Which instruction should the nurse provide to a client who is preparing to have a cystoscopy?
      A)Lay prone for 24 hours after the procedure.
      B)Report any painful urination, blood in urine, or fever.
      C)Avoid strenuous activity and sports for at least 2 weeks.
      D)Report any allergies to shellfish or iodine.
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