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    Exam Review

    1. While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?
      A)Serum albumin.
      B)Neutrophil count.
      C)Serum blood glucose (BG) level.
      D)Hematocrit.
    2. The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which response by the client indicates understanding?
      A)Soak feet daily in hot water no longer than 10 minutes.
      B)Include no more than 1-2 alcoholic beverages in diet per day.
      C)Remember exercise will not affect blood glucose levels.
      D)Keep any wounds covered with an antibiotic ointment.
    3. When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?
      A)Leave the client's room and return later in the day.
      B)Refer client to the social worker for support therapy.
      C)Encourage client to implement relaxation techniques.
      D)Explain that insulin is a life-saving drug for the client.
    4. The nurse is caring for a 3-year-old client who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?
      A)The pressure dressing at right femoral area is moist and oozing blood.
      B)Pulse distal to the femoral artery is weaker on left foot than right foot.
      C)Right foot is cool to the touch and appears pale and blanched.
      D)Blood pressure trend is downward and pulse is rapid and irregular.
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    Exam Review

    1. After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?
      A)Notify information services department of the situation.
      B)Print electronic medical record (EMR) from backup server.
      C)Wait for notification that the system has been rebooted.
      D)Identify information as late entry in the record.
    2. The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?
      A)Monitor blood glucose level.
      B)Maintain strict intake and output.
      C)Assess warmth of extremities.
      D)Keep head of bed raised 45 degrees.
    3. A client who received an open reduction and internal fixation (ORIF) of the right femur after experiencing a fall at home experiences a sudden onset of increasing confusion and agitation. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?
      A)Fall at home as reason for admission.
      B)Currently prescribed medications.
      C)Increasing confusion of the client.
      D)Client's healthcare power of attorney.
    4. A client is recovering in the critical care unit following a cardiac catheterization. IV nitroglycerin and heparin are infusing. The client is sedated but responds to verbal instructions. After changing positions, the client reports pain at the right groin insertion site. Which action should the nurse implement?
      A)Assess distal lower extremity capillary refill.
      B)Check femoral site for hematoma formation.
      C)Evaluate the integrity of the IV insertion site.
      D)D Stimulate the client to take deep breaths.
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    Exam Review

    1. The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event?
      A)Outreach for support group information.
      B)Domestic violence assistance.
      C)Blood pressure screening.
      D)Immunizations that are available.
    2. After years of struggling with weight management, a middle-aged adult client is evaluated for gastroplasty. The client has experienced difficulty with managing diabetes mellitus and hypertension, but is approved for surgery. Which intervention is most important for the nurse to include in this client's plan of care?
      A)Observe for signs of depression.
      B)Apply sequential compression stockings.
      C)Provide a wide variety of meal choices.
      D)Monitor for urinary incontinence.
    3. 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 allergies to shellfish or iodine.
      C)Report any painful urination, blood in urine, or fever.
      D)Avoid strenuous activity and sports for at least 2 weeks.
    4. A client who is obese reports severe pain and is unable to bear weight in the right ankle after making dietary changes 3 weeks ago for weight loss. The client's medical history includes hypertension, gouty arthritis, and cholecystitis. Which instruction should the nurse include in the discharge teaching?
      A)Avoid the consumption of wine, beer, and coffee.
      B)Substitute natural fruit juices for carbonated drinks.
      C)Encourage active range of motion to limit stiffness.
      D)Use electric heating pad when pain is at its worse.
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    Exam Review

    1. The nurse is preparing a client for an outpatient thoracentesis. Which statement made by the client should the nurse recognize as needing additional education?
      A)Anticipate a stinging feeling during needle insertion.
      B)Prepare to sit forward with arms propped on a table.
      C)Expect a persistent cough after the procedure.
      D)Limit activity for a day or two after returning home.
    2. A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines. Which instruction should the nurse provide the parent about care of the infant after the injections?
      A)Administer children's aspirin to help prevent inflammation.
      B)Keep the infant home from daycare for the next two days.
      C)Any level of fever is serious and should be reported right away.
      D)Apply a cool pack to the injection site to reduce discomfort.
    3. The nurse observes that a client with ascites is dyspneic. Which action should the nurse implement first?
      A)Measure the vital signs.
      B)Assist to a high Fowler's position.
      C)Initiate deep breathing exercises.
      D)Auscultate breath sounds.
    4. A client with coronary artery disease (CAD) is admitted to the medical unit for testing. The client describes having had frequent episodes of angina over the last few days prior to admission. The client is now experiencing shortness of breath, nausea, and chest pressure. After obtaining the client's vital signs, which action should the nurse take next?
      A)Verify troponin level assessments are scheduled every 3 to 6 hours for a series of three.
      B)Initiate dim lighting, lower alarm volumes, and control traffic in and out of the room area.
      C)Count and record the number of premature ventricular contractions per minute.
      D)Apply oxygen via nasal cannula and titrate to keep oxygen saturation above 93%.
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    Exam Review

    1. A client with metastatic cancer who was taking hydromorphone PO at home is now receiving the medication IV while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete?
      A)Respiratory rate.
      B)Pain scale.
      C)Blood pressure.
      D)Level of consciousness.
    2. A client receives a prescription for 1 L of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)
    3. An older adult client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). The client has facial paralysis and cannot move the left side of the body. When entering the room, the nurse finds the client's spouse tearful and trying unsuccessfully to give the client a drink of water. Which action should the nurse take?
      A)Obtain thickening powder before providing any more fluids.
      B)Assist the spouse and carefully give the client small sips of water.
      C)Ask the spouse to stop and assess the client's swallowing reflex.
      D)Give the spouse a straw to help facilitate the client's drinking.
    4. The charge nurse observes a new nurse preparing to irrigate an intravenous catheter. The new nurse brought a luer-lock tipped syringe. Which action should the charge nurse take?
      A)Instruct the nurse to use water with 5% dextrose (DW).
      B)Send an unlicensed assistive personnel to gather equipment.
      C)Prompt the nurse to apply povidone to the site.
      D)Direct the nurse to attach the luer-lock tip to the irrigation port.
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    Exam Review

    1. When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? Select all that apply.(SATA)
      A)Pickled olives.
      B)Fruits without sauce.
      C)Fresh or frozen vegetables without sauce.
      D)Cottage cheese.
      E)Canned soup.
    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)Neutrophil count.
      B)Hematocrit.
      C)Platelet count.
      D)Serum sodium level.
    3. A client with a recent exacerbation of heart failure reports to the nurse feeling uncomfortable and anxious, with a sensation of the flopping in the chest. While waiting for an electrocardiogram (ECG), which assessment is most important for the nurse to obtain?
      A)Volume of pedal pulses.
      B)Length of capillary refill.
      C)Rhythm of apical pulse.
      D)Degree of skin elasticity.
    4. 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)A female adolescent admitted with multiple genital Herpes simplex II lesions.
      B)Twin siblings admitted with scarlet fever that is complicated with pneumonia.
      C)An older client with scabies who is admitted from an extended care facility.
      D)A client with a positive Mantoux and sputum cultures results positive for acid-fast bacillus (AFB).
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