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    Exam Review

    1. A nurse in an acute mental-health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client?
      A)Plan to remove the restraints as soon as the client is calm.
      B)Ensure that the provider has signed a prescription for restraints within 48 hr.
      C)Offer the client a nutritious snack every 4 hr.
      D)Monitor the client's range of motion every 60 min.
    2. A nurse in a provider's office is reinforcing teaching about cigarette smoking with a client. Which of the following adverse effects should the nurse include in the teaching?
      A)Decreased hemoglobin
      B)Bradycardia
      C)Decreased blood pressure
      D)Somnolence
    3. A nurse in an Inpatient mental health facility is reinforcing teaching with a client who signed a consent form for electroconvulsive therapy. Which of the following statements by the client indicates an understanding of the procedure?
      A)"I might have occasional seizures for several days after the procedure."
      B)"I might have short-term memory loss after the procedure."
      C)"I will have a urinary catheter in place during the procedure."
      D)"I will need to follow a full-liquid diet for 24 hours after the procedure."
    4. A nurse is collecting data from a client who has heart failure. The nurse notes the client has crackles in the bases of the lungs, shortness of breath, and a respiratory rate of 24/min. Which of the following actions should the nurse take?
      A)Maintain the client in high-Fowler's position.
      B)Instruct the client to cough every 4 hr.
      C)Increase the client's intake of oral fluids.
      D)Encourage the client to ambulate to loosen secretions.
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    Exam Review

    1. A nurse is caring for a client who asks why her newborn is receiving a phytonadione injection. Which of the following statements should the nurse make?
      A)This medication prevents your baby from developing bleeding problems."
      B)"This medication enhances regulation of your baby's temperature."
      C)"This medication enhances your baby's immune response."
      D)"This medication prevents your baby from developing jaundice
    2. A nurse is administering pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?
      A)Improved respiratory function
      B)Reduced fat in the stools
      C)Improved absorption of vitamins B and C
      D)Decreased sodium excretion
    3. A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. The nurse should place the client in which of the following positions?
      A)Supine
      B)Left lateral
      C)Semi-Fowler's
      D)Dorsal recumbent
    4. A nurse is monitoring a client who has received external radiation for throat cancer. Which of the following findings should the nurse expect?
      A)Loose stools
      B)Bladder infection
      C)Increased appetite
      D)Loss of taste
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    Exam Review

    1. A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect?
      A)Clammy skin
      B)Bounding pulse
      C)Elevated blood pressure
      D)Fruity breath odor
    2. A nurse enters the room of a school-age child and finds them on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
      A)Restrain the child's upper extremities.
      B)Turn the child onto their back
      C)Place a padded tongue blade in the child's mouth.
      D)Place a pillow under the child's head.
    3. A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?
      A)Coll the tubing on the bed above the collection bag
      B)Instruct the client to hold the drainage bag at waist height when ambulating
      C)Secure the tubing with adhesive tape to the lower abdomen.
      D)Collect a sterile specimen from the urinary drainage bag.
    4. A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?
      A)Document the event in the client's progress notes.
      B)Inform the client of the APs' actions.
      C)Tell the APs to stop the conversation.
      D)Submit an incident report to the risk manager.
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    Exam Review

    1. A nurse is collecting data from a client who has heart failure and is taking furosemide. Which of the following findings should indicate to the nurse that the medication is effective?
      A)Decreased BUN level
      B)Increased urinary output
      C)Decreased hemoglobin level
      D)Increased weight of 0.91 kg (2 lb.)
    2. A nurse in an acute care facility is reviewing medication administration protocol with another nurse. Which of the following information should the nurse include in the review?
      A)Document the administration of medications after all assigned clients have been medicated.
      B)Check the clients' allergy bands with each medication administration.
      C)Read medication labels twice before administration,
      D)Use one client identifier before administering medication.
    3. A nurse is collecting data from a 4-month-old infant at a well-child visit. For which of the following findings should the nurse notify the provider?
      A)Posterior fontanel closed
      B)Anterior fontanel closed
      C)Plays with toes
      D)Moves objects to mouth
    4. A nurse is reinforcing teaching about preventing dental caries with the parent of a 12-month-old toddler. Which of the following instructions should the nurse provide?
      A)"Floss between your child's teeth before brushing."
      B)"Position the bristles of your child's toothbrush against the teeth at a 90-degree angle."
      C)"Clean the teeth with a small, soft-bristled toothbrush."
      D)"Use a 5-inch strip of toothpaste on the toothbrush."
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    Exam Review

    1. A nurse is collecting data from a client who reports difficulty sleeping at night. Which of the following client statements indicates an understanding of sleep promotion?
      A)"I moved the television to my bedroom for background noise."
      B)"I go to the 24-hour gym shortly before I go to bed."
      C)"I am eating dinner later in the evening."
      D)"I am going to bed at the same time every night."
    2. A nurse is providing site care for a child who has a gastrostomy enteral tube. Which of the following actions should the nurse take?
      A)Apply water-soluble lubricant to the site.
      B)Tape the tube to the child's cheek.
      C)Attach an extension tube to the site's opening prior to use.
      D)Secure the tubing to the child's abdomen.
    3. A nurse is using a glucometer to measure a client's capillary blood glucose level. Which of the following actions should the nurse take?
      A)Select the central tip of a finger.
      B)Wear sterile gloves.
      C)Keep the finger in a dependent position.
      D)Milk or massage the finger site.
    4. A nurse is reinforcing teaching with a client who has a new diagnosis of COPD. Which of the following statements by the client indicates an understanding of the teaching?
      A)"I should do aerobic exercises once per day."
      B)"I should practice pursed-lip breathing exercises."
      C)"I will increase my fluid intake to 1,700 milliliters per day."
      D)"I will consume low-protein, low-calorie foods."
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    Exam Review

    1. A nurse on a medical-surgical unit is planning care for four clients. The nurse should plan to use sterile gloves when performing which of the following procedures?
      A)Changing a central venous catheter dressing for a client who is receiving IV therapy
      B)Instilling an ophthalmic ointment for a client who has a corneal abrasion
      C)Inserting an NG tube for a client who needs continuous enteral feedings
      D)Administering an IM injection to a client who has bacterial pneumonia
    2. A nurse is collecting data from a client who has pernicious anemia. The nurse should identify that which of the following findings increases the client's risk for injury?
      A)Uses a firm-bristled toothbrush
      B)Increased intake of green, leafy vegetables
      C)Drinks 2,500 mL of fluid per day
      D)Wears a face mask around others
    3. A nurse is reinforcing discharge teaching with a client who has undergone a vein stripping of the right leg. Which of the following instructions should the nurse include in the teaching?
      A)Keep legs in a dependent position.
      B)Wrap the leg with an elastic bandage.
      C)Maintain bed rest for 48 hr.
      D)Implement a sodium-restricted diet.
    4. A nurse is receiving change-of-shift report on four clients. Which of the following clients should the nurse plan to see first?
      A)A client who has a femur fracture and reports numbness of the toes
      B)A client who has cirrhosis and severe pruritus
      C)A client who had a laparoscopic appendectomy 8 hr. ago and is awaiting discharge
      D)A client who had a renal biopsy 3 hr. ago and has pink-tinged urine
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