Exam Review

A client diagnosed with glaucoma receives a new prescription for dorzolamide. Prior to administering the medication, the nurse should review the electronic medical record for which allergy?
A)lodine.
B)Latex.
C)Penicillin.
D)Sulfonamide.
Which task should the nurse delegate to an unlicensed assistive personnel (UAP)?
A)Bring a sterile chest drainage unit from central supply to the unit.
B)Evaluate a client's urinary catheter for proper drainage.
C)Call the pharmacy to obtain a client's next antibiotic dose.
D)Observe a client's gait to determine the need for assistance.
A client with fluid overload receives a prescription for fluid restriction of 1 liter/day and a diuretic. Which action(s) should the nurse perform to best evaluate the effectiveness of the treatment? Select all that apply.(SATA)
A)Calculate the intake and output.
B)Assess pulse rate.
C)Monitor the temperature.
D)Checking for orthostatic hypotension.
E)Obtain a daily weight.
A client is receiving a secondary infusion of erythromycin 1 grams in 100 mL dextrose 5% in water (D5W) to be infused in 30 minutes. How many mL/hour should the nurse program the infusion pump? (Enter numerical value only.)

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Exam Review

The nurse provides sliding scale insulin administration instructions to an adult who was recently diagnosed with diabetes mellitus. The client demonstrates an understanding of the instructions provided by performing the procedure in which order? (Arrange with the first on top and the last on the bottom.)
A)Obtain blood glucose level.1
B)Draw insulin into insulin syringe.3
C)Verify the insulin prescription.2
D)Cleanse the selected site.4
A pre-school age child with a congenital heart defect is brought to the clinic by the parent because of a fever and an earache. During the assessment, the parent asks the nurse why the child is at the 5th percentile for weight and height for age. Which response is best for the nurse to provide?
A)"You should not worry about the growth tables. They are only averages for children."
B)"Haven't you been feeding according to recommended daily allowances for children?"
C)"Does your child seem mentally slower than his peers also?"
D)"The smaller size is probably due to the heart disease."
An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?
A)Palpate the client's suprapubic area for distention.
B)Instruct in effective techniques to cleanse the glans penis.
C)Obtain a urine specimen for culture and sensitivity.
D)Advise the client to maintain a voiding diary for one week.
The nurse is planning a class about blood glucose monitoring for a group of clients with diabetes mellitus. Which timing of glucose testing would apply for any client regardless of the client's age or type of diabetes?
A)Before going to bed.
B)During acute illness.
C)Prior to exercising.
D)Immediately after meals.

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Exam Review

A client's respiratory assessment reveals crackles, decreased tactile fremitus, and a dull sound in left lower chest during percussion. Which condition should the nurse document in the electronic medical record?
A)Pleural effusion.
B)Emphysema.
C)Bronchitis.
D)Pneumothorax.
After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?
A)Ask the client about gastrointestinal pain.
B)Auscultate for bowel sounds in all quadrants.
C)Measure the client's fluid intake and output.
D)Monitor the client's serum electrolyte levels.
Which snack selection indicates to the nurse that a school-age child with gastroesophageal reflux understands the dietary restrictions?
A)Sugar cookies.
B)Pizza.
C)Tacos.
D)Chocolate milkshake.
While caring for a client after a small bowel resection, the nurse is informed that the client has a history of methicillin-resistant Staphylococcus aureus (MRSA). To reduce the risk of recurrence of the MRSA in the postoperative wound, which intervention is most important for the nurse to implement?
A)Report any increase in the white blood cell count.
B)Change the surgical dressing when soiled.
C)Wear a face mask while performing wound care.
D)Instruct the family to adhere to contact precautions.

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Exam Review

Patient data Exhibits The nurse considers the brief interaction with the client and the triage report. Which finding(s) should the nurse investigate further? Select all that apply.(SATA)
A)Left arm that is cool to touch
B)Decreased range of motion
C)Swelling at the site of injury
D)Intense pain reported by client
E)Oxygen saturation 95% on room air
F)Blood pressure of 136/90 mm Hg
G)Nausea and fatigue reported by client
H)Bone misalignment
Patient Data Exhibits For each assessment finding, click to indicate whether the findings from the client's assessment are generally associated with rotator cuff injury and/or humeral fracture. Each column must have at least one response selected.
Rotator Cuff Injury Humeral Fracture
Reduced pulse distal to injury ✓
Decreased range of motion ✓ ✓
Coolness of skin ✓
Pain with movement ✓ ✓
1+ strength in left upper extremity ✓
Patient Data Exhibits Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. Based on the client's condition, the priority need will be to address ▾ pain. In addition, he will need interventions to prevent ▾ compartment syndrome_.
Dropdown 1:
Option 1: pain
Option 2: mobility
Option 3: swelling
Dropdown 2:
Option 1: venous thromboembolism
Option 2: compartment syndrome
Option 3: fat embolism syndrome

	Rotator Cuff Injury	Humeral Fracture
Reduced pulse distal to injury		✓
Decreased range of motion	✓	✓
Coolness of skin		✓
Pain with movement	✓	✓
1+ strength in left upper extremity	✓

Patient Data Exhibits The nurse reviews the prescriptions and plans initial steps for caring for the client. Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

	Indicated	Contraindicated
Palpate and compare radial pulses.	✓
Administer ondansetron 4 mg IVP.	✓
Perform range of motion.		✓
Provide morphine 2 mg IV push (IVP).		✓
Inspect the bandage for drainage.	✓
Check capillary refill on bilateral upper extremities.	✓

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Exam Review

Patient Data Exhibits
(Highlight — findings requiring follow-up are marked)
Patient Data

Exhibits

Click to highlight the findings that would indicate the client is progressing as expected.

The nurse assesses the client. The client reports he was able to sleep through the night. The client notes continued numbness in his left arm, along with a tingling sensation, and is not able to move his fingers. The client reports mild nausea and has no desire to eat breakfast. There is a 1.18 in (3 cm) by 1.97 in (5 cm) area of blood noted on the bandage. The left arm is warm to touch. The client's left shoulder and collarbone are symmetric.
A client with cirrhosis of the liver is having numerous, liquid, incontinent stools, and continues to be confused. In reviewing the client's laboratory studies, the nurse identifies an elevated serum ammonia level. Based on this finding, which prescription is most important for this client to receive?
A)Furosemide.
B)Intravenous (IV) human albumin.
C)Lactulose.
D)Loperamide.
Which finding should the nurse recognize as a potential complication in a client with hypertension?
A)Polydipsia and polyuria.
B)Elevated blood urea nitrogen.
C)Dry and irritated skin.
D)New onset of bradycardia.
The nurse assesses a client being treated for Herpes zoster (shingles). Which assessment(s) should the nurse include when evaluating the effectiveness of treatment? Select all that apply.(SATA)
A)Heart sounds.
B)Pain scale.
C)Bowel sounds.
D)Functional ability
E)Skin integrity.

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Exam Review

The nurse is caring for a client with chronic kidney disease (CKD). Which meal selection should the nurse recommend to the client?
A)Pasta with fish and an orange.
B)Canned ham and green beans.
C)Steak and baked potato with butter and cheese topping.
D)Chicken, yams, pinto beans and pecans.
A client on the mental health unit has been scowling and rapidly pacing up and down the hall for several minutes. Which behaviors are most important for the nurse to monitor?
A)Argumentativeness and use of profanity.
B)Periodic sighing and shaking the head.
C)Decreased activity level and change in affect.
D)Repeated requests for attention from the nurse.
The nurse notes that a client with depression has been more withdrawn and noncommunicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?
A)Engage the client in non-threatening conversations.
B)Encourage the client's family to visit more often.
C)Encourage the client to participate in group activities.
D)Schedule a daily conference with the social worker.
The wife of a newly diagnosed client with Parkinson's disease asks the nurse if alternative or complimentary medical therapies might cure the disease. Which response should the nurse provide?
A)Encourage the wife to voice her feelings about having a husband with Parkinson's disease.
B)Tell the wife that her husband's neurologist would know more about alternative treatments to cure Parkinsonism.
C)Explain that there are no known conventional, alternative, or complimentary therapies that cure Parkinson's disease.
D)Compile a list of alternative medications that are effective in curing Parkinson's disease.

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