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    Exam Review

    1. A nurse is caring for a 3-year-old child immediately following a tonic-clonic seizure. Which of the following actions should the nurse take?
      A)Offer the child sips of clear fluids.
      B)Place the child in a supine position.
      C)Administer an oral antiepileptic medication.
      D)Check the child for oral injuries.
      E)None
      F)None
    2. A nurse is caring for a client who has paranoid schizophrenia and believes that they are being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make?
      A)The psychiatric staff is not FBI. They are here to help you.
      B)This must be very frightening for you. Let's talk more about it.
      C)What makes you think the staff is following you?
      D)Why do you feel the staff is the FBI?
    3. A nurse is reinforcing teaching about advance directives with a client who has end-stage heart failure. Which of the following statements by the client indicates an understanding of the teaching?
      A)I should discuss this document with my family after I sign it.
      B)I am not allowed to change my mind once I sign this document.
      C)An atorney will need to notarize this document for it to be valid.
      D)My partner needs to be present when I sign this document.
    4. A nurse is reinforcing teaching with a client who has diabetes mellitus about a 24-hour creatinine clearance test. Which of the following statements should the nurse include in the teaching?
      A)You should eat a protein-rich diet during the collection period.
      B)You should record your blood glucose level each time you void.
      C)You can begin collection of urine after discarding your first morning void.
      D)You can cleanse your perineal area with an antiseptic towel each time before you void.
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    Exam Review

    1. A nurse in an adult day care facility is contributing to the plan of care for a client whose family reports recent confusion and memory loss. Which of the following strategies should the nurse include in the plan?
      A)Maintain low-level lights in common areas.
      B)Give the client several meal options at lunchtime.
      C)Confront the client regarding inappropriate behavior.
      D)Use symbols in the communal room signage.
    2. A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hours PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this alert care incident?
      A)Incident report
      B)Nursing care plan
      C)Controlled substance inventory record
      D)Provider's progress notes
    3. A nurse is caring for a client who follows a kosher diet. Which of the following menu items should the nurse include on the tray?
      A)Clam chowder
      B)Shrimp salad
      C)Roasted salmon
      D)Pulled pork sandwich.
    4. A nurse is caring for a client who has end-stage kidney disease. The client has decided to stop dialysis treatment. Which of the following actions should the nurse take?
      A)Support the client's decision to stop the treatment.
      B)Tell the client she should discuss this decision with her family.
      C)Ask the facility chaplain to visit the client.
      D)Discuss alternative treatment methods with the client.
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    Exam Review

    1. A nurse is reinforcing teaching with a client who is about to start using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include in the teaching?
      A)Tilt your head forward while inhaling.
      B)Take three quick breaths while depressing the canister.
      C)Close your mouth around the mouthpiece.
      D)Exhale immediately after inhaling.
    2. A nurse is reinforcing teaching with a new parent about bathing her newborn. Which of the following statements should the nurse include?
      A)Apply talcum powder daily after bathing in order to prevent diaper rash.
      B)Use an alkaline soap to bathe the baby.
      C)Perform sponge baths until the baby's umbilical cord falls off.
      D)Ensure the bath water is at least 96 degrees Fahrenheit.
    3. A nurse is reinforcing teaching with a client who has a new prescription for atorvastatin. For which of the following adverse effects should the nurse instruct the client to monitor and report to the provider?
      A)Hypoglycemia
      B)Palpitations
      C)Daytime drowsiness
      D)Muscle pain
    4. A nurse is assisting with the care of a client in a PACU. Provider Prescriptions 1100: Oxygen 2 to 5 L/min via nasal cannula to maintain oxygen saturation greater than 92%. Which of the following actions should the nurse take during the management of oxygenation for this client? Select all that apply.(SATA)
      A)Place the client in the supine position.
      B)Prepare to administer oxygen via Venturi face mask.
      C)Add a humidifier to the oxygen device.
      D)Encourage client to perform deep breathing exercises.
      E)Examine the client's nail beds.
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    Exam Review

    1. A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment?
      A)Slurred speech
      B)Hypotension
      C)New onset of hearing loss
      D)Hyperthermia
    2. 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 hemoglobin level
      B)Increased urinary output
      C)Decreased BUN level
      D)Increased weight of 0.91 kg (2 lb)
    3. A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect?
      A)Memory loss that disrupts ADLs
      B)Catatonia
      C)Illusions
      D)Pressured speech
    4. A nurse is reinforcing teaching to a newly licensed nurse about bowel sounds. Which of the following characteristics should the nurse use to describe hyperactive bowel sounds?
      A)Sounds are high-pitched
      B)Can be a result of a paralytic ileus
      C)Indicates decreased motility
      D)Sounds are soft and at a rate of 1/min
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    Exam Review

    1. A nurse is caring for a newly admited older adult client. Nurses' Notes Day 1, 12:00: Transferred to medical-surgical unit from emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by adult child. Client in visibly soiled night clothes with multiple stains, including what appears to be dried blood. Hair, teeth, and fingernails unclean. Strong body odor noted. Bruising of various stages noted around upper arms, back, shoulders, and neck area. Client is soft-spoken, speaks almost in a whisper, does not make eye contact with nurse. Client looks at their child before answering the nurse's questions and, when asked how the injury occurred, mumbles "I don't know. Ask them." Client's child states, "He gets confused sometimes. I can answer your questions." Which of the following interventions should the nurse recommend to include in the client's plan of care? Select all that apply.(SATA)
      A)Tell the client's child that they will be reported for maltreatment of the client.
      B)Ask the client's child to provide details regarding the client's fractured arm.
      C)Discuss respite care options with the client's child.
      D)Speak to the client privately.
      E)Provide legal advice to the client regarding power of atorney.
    2. A nurse is administering a client's morning oral medications. Which of the following actions should the nurse take?
      A)Verify the medication three times with the medication administration record.
      B)Document medication administration prior to administering medication.
      C)Administer time-critical medication 60 min before or after the scheduled time.
      D)Identify the client by using one identifier before giving the medication.
    3. A nurse is preparing to administer eye drops to a child. Which of the following actions should the nurse take?
      A)Apply pressure to the lacrimal punctum after administering the drops.
      B)Position the child side-lying on the bed before administering the drops.
      C)Wipe from the outer to the inner canthus after administering the drops.
      D)Flush the eye with normal saline solution before administering the drops.
    4. A nurse in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?
      A)Family medical history
      B)Medications taken prior to admission
      C)Physical assessment findings
      D)Medical health insurance claims
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    Exam Review

    1. A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?
      A)Clean the stoma using an inward to outward circular motion.
      B)Cleanse the inner cannula with isopropyl alcohol.
      C)Ensure at least three finger widths of space under tracheostomy ties.
      D)Prepare sterile supplies after removing the inner cannula.
    2. A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority?
      A)Ecchymosis on the inner left thigh
      B)One fingerbreadth of space between the cast and the skin
      C)Diminished pulses on the affected extremity
      D)Client report of muscle spasms of the left leg
    3. A nurse is caring for a client who has a prescription for warfarin. Which of the following laboratory tests should the nurse monitor?
      A)Triiodothyronine
      B)Blood urea nitrogen
      C)Arterial blood gases
      D)Prothrombin time
    4. A nurse is assisting with the care of a client. Exhibits Complete the following sentence. After notifying the provider, the nurse should first ▾ administer nitroglycerin and then ▾ obtain an electrocardiogram (ECG). (Separate your answers with a comma ',')
      Dropdown 1:
      Option 1: apply ice packs to the chest.
      Option 2: assess for signs of stroke.
      Option 3: administer nitroglycerin
      Option 4: provide a high-fat meal.
      Dropdown 2:
      Option 1: administer a laxative.
      Option 2: obtain an electrocardiogram (ECG)
      Option 3: perform a throat culture.
      Option 4: check blood glucose levels.
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