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    Exam Review

    1. A nurse is caring for a client in the emergency department. Exhibits Complete the following sentence by using the lists of options. The client is likely experiencing ▾ Opioid intoxicationas evidenced by▾ Pupil characteristic.
      Dropdown 1:
      Option 1: Opioid intoxication
      Option 2: Alcohol withdrawal
      Option 3: Opioid withdrawal
      Option 4: Alcohol intoxication
      Dropdown 2:
      Option 1: Current temperature
      Option 2: Amount of alcohol consumed
      Option 3: Breath sounds
      Option 4: Pupil characteristic
    2. A nurse is caring for an 18-month-old toddler in the emergency department. Exhibits For each potential assessment finding, click to specify if the finding is consistent with Epiglottitis, Respiratory Syncytial Virus, or Acute Streptococcal Pharyngitis. Each finding may support more than 1 disease process.
      EpiglottitisRespiratory Syncytial virusAcute Streptococcal Pharyngitis
      Hypoxia✓✓
      Tachypnea✓✓
      Fever✓✓✓
      Exudate on pharynx✓
      Drooling✓
      Wheezing upon auscultation✓
    3. A nurse is training a newly licensed nurse. The newly licensed nurse asks if she can delegate the task of weighing several clients to an assistive personnel (AP). Which of the following responses should the nurse make?
      A)"You can delegate this task if the AP has been trained to use our scales."
      B)"You should not delegate this task because you have the capability to obtain clients' weights.”
      C)"You should not delegate this task because it requires nursing judgment."
      D)"You can delegate this task to an AP for new clients before performing a nursing assessment.”
    4. A nurse on a pediatric unit is caring for a preschooler who is postoperative following an appendectomy. Exhibits Complete the following sentence by using the lists of options. The child is at risk for developing ▾ pneumoniaas evidenced by ▾ shallow breathingand▾ lack of incentive spirometer use.
      Dropdown 1:
      Option 1: peritonitis
      Option 2: wound infection
      Option 3: pneumonia
      Dropdown 2:
      Option 1: bowel sounds
      Option 2: shallow breathing
      Option 3: temperature
      Dropdown 3:
      Option 1: surgical dressing
      Option 2: abdominal tenderness
      Option 3: lack of incentive spirometer use
    Page 1 of 45

    Exam Review

    1. A nurse is reviewing a client's cardiac rhythm strips and notes a constant P.R interval of 0.35 seconds. Which of the following dysrhythmias is the client displaying?
      A)Atrial fibrillation
      B)First-degree atrioventricular block
      C)Complete heart block
      D)Premature atrial complexes
    2. A nurse is caring for a client in an orthopedic unit. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing ▾ compartment syndromeand▾ osteomyelitis.
      Dropdown 1:
      Option 1: compartment syndrome
      Option 2: deep vein syndrome
      Option 3: osteomyelitis
      Option 4: fat embolism syndrome
      Dropdown 2:
      Option 1: compartment syndrome
      Option 2: deep vein syndrome
      Option 3: osteomyelitis
      Option 4: fat embolism syndrome
    3. A nurse is preparing to teach the parents of a child who has cystic fibrosis. Which of the following instructions should the nurse plan to include?
      A)Trim the fat from red meat prior to cooking.
      B)Give the child hot foods to reduce the sense of fullness.
      C)Provide a diet high in protein and calories,
      D)Administer pancreatic enzymes 30 min after meals
    4. A nurse is assessing a client who is postoperative following a coronary artery bypass graft surgery. The nurse should identify that which of the following findings is an early indication of cardiac tamponade?
      A)Coarse lung sounds
      B)Decreased jugular vein distention
      C)Widening pulse pressure
      D)Muffled heart sounds
    Page 2 of 45

    Exam Review

    1. A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse plan to include?
      A)Critical pathways have an unlimited timeframe for completion.
      B)Nurses should discontinue the critical pathway if variances occur.
      C)Nurses' notes are used to create the critical pathway.
      D)Critical pathways should reduce health care costs.
    2. A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make?
      A)“Rise slowly when getting out of bed."
      B)"Eat foods that are high in sodium.”
      C)“Taking furosemide can cause you to be overhydrated."
      D)"Taking furosemide can cause your potassium levels to be high."
    3. A nurse is preparing a client for transfer to a long-term rehabilitation facility following a below-the-knee amputation of the right leg. Which of the following actions should the nurse take to protect the client's confidentiality?
      A)Email the client's health information to the facility in an unencrypted file.
      B)Discuss the client's response to the transfer with another staff nurse.
      C)Provide a verbal report of the clients condition to the paramedic performing the transfer.
      D)Fax the client's name and identifiable information to the rehabilitation facility.
    4. A nurse is assessing a client who is receiving morphine IV for pain. Which of the following findings should the nurse report to the provider first?
      A)Bowel movement 5 days ago
      B)Pupil diameter 6 mm
      C)Blood pressure 80/40 mm Hg
      D)Urinary output 120 mL/4 hr
    Page 3 of 45

    Exam Review

    1. A nurse is performing wound care for a client who has an abdominal incision. Which of the following techniques should the nurse implement?
      A)Irrigate the wound with a low-pressure flow of solution.
      B)Cleanse the insertion site of the drain using a circular motion toward the center.
      C)Cleanse the wound starting at the bottom and moving upward.
      D)Irrigate the wound using a 10.mL Syringe.
    2. A nurse is monitoring a client who is receiving a blood transfusion. The client reports, “My skin itches and I feel flushed.” Which of the following actions should the nurse take?
      A)Remove the peripheral IV site.
      B)Infuse 0.9% sodium chloride through the infusion set tubing.
      C)Stop the transfusion of the blood.
      D)Monitor the client's vital signs every 30 min.
    3. A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port?
      A)A 25-gauge needle
      B)A noncoring needle
      C)A butterfly needle
      D)An angiocatheter
    4. A nurse is assessing a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate 4 hr ago. The nurse notes pink-tinged urine in the drainage bag. Which of the following actions should the nurse take?
      A)Warm the irrigation solution.
      B)Perform the Credés maneuver.
      C)Replace the indwelling urinary catheter
      D)Maintain the irrigation solution rate.
    Page 4 of 45

    Exam Review

    1. A nurse is caring for a client who is in labor and has received an epidural. Which of the following actions should the nurse take?
      A)Reposition the client sideways each hour.
      B)Have protamine sulfate available at the bedside.
      C)Monitor the client for hypertension.
      D)Decrease the maintenance infusion rate of IV fluid.
    2. A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
      A)Place locks at the tops of exterior doors.
      B)Wear clothing with zippers instead of buttons.
      C)Encourage physical activity prior to bedtime.
      D)Replace the carpet with hardwood floors.
    3. A nurse is caring for a client who has hearing loss. While communicating with the client which of the following actions should the nurse take?
      A)Sit next to the client when speaking to them.
      B)Lower the tone of voice at the end of each sentence.
      C)Emphasize vowel sounds when speaking.
      D)Decrease background noise when talking with the client.
    4. A nurse is caring for a client who has a fractured leg and rates their pain as 7 on a scale of O to 10. Which of the following medications should the nurse expect to administer?
      A)Fentanyl
      B)Hydrocodone
      C)Aspirin
      D)Acetaminophen
      E)None
      F)None
    Page 5 of 45

    Exam Review

    1. A nurse is caring for a child who reports migraine headaches for the past 4 months. Which of the following actions should the nurse take first?
      A)Review the child's electronic pain diary.
      B)Request a change in medication from the provider,
      C)Set up an appointment with the school nurse.
      D)Refer the family to a chronic pain support group.
    2. A burse is assessing a client who is 3 days postoperative and has a nonmechanical obstruction of the small bowel. Which of the following findings should the nurse expect?
      A)Metabolic acidosis
      B)Hyperactive bowel sounds
      C)Distended abdomen
      D)Passing flatus
    3. A nurse is caring for a client in active labor. Exhibits The nurse is assuming care for the client at 0305. For each nursing action, click to specify if the nursing action is essential or contraindicated for the client.
      EssentialContraindicated
      Assist the client with ambulation.✓
      Monitor for elevated temperature.✓
      Inform the client to expect drowsiness.✓
      Assess for urinary retention.✓
      Encourage the client to turn from side to side.✓
    4. A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse plan to take?
      A)Apply a tourniquet below the venipuncture site.
      B)Choose a vein that is palpable and straight.
      C)Elevate the client's arm prior to insertion.
      D)Select a site on the client's dominant arm.
    Page 6 of 45