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    Exam Review

    1. A nurse is assisting with the care of a newborn. For each potential nursing intervention, click to specify if the action appropriate, nonessential, or contraindicated for the newborn.
      AppropriateNonessentialContraindicated
      Maintain an opaque mask over the newborn's eyes when under the lights.✓
      Monitor the frequency and consistency of stools.✓
      Apply a mild, fragrance free lotion to exposed skin BID.✓
      Measure the occipital frontal-circumference (OFC) daily.✓
      Offer glucose water supplements between feedings.✓
      Reposition the newborn every 2 to 3 hr.✓
    2. A nurse is assisting in the care of a client. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.
      AnticipatedContraindicated
      Check deep tendon reflexes.✓
      Discontinue fluoxetine.✓
      Administer citalopram.✓
      Administer phenelzine.✓
      Administer propranolol.✓
    3. A nurse in the emergency department is assisting with the care of a client. For each assessment finding below, click to specify if the finding is consistent with appendicitis, diverticulitis, or celiac disease. Each finding may support more than 1 disease process.
      AppendicitisCeliac DiseaseDiverticulitis
      Muscle guarding✓
      Increased temperature✓✓
      Nausea and vomiting✓✓
      Abdominal pain✓✓✓
      Elevated WBC count✓✓
    4. A nurse is assisting in the care of an 8-month-old infant in the emergency department (ED). Select the 3 priority actions the nurse should take.(SATA)
      A)Apply continuous pulse oximeter.
      B)Reinforce instructions for parent regarding use of breast pump to express milk.
      C)Administer acetaminophen.
      D)Assist with insertion of peripheral intravenous access device.
      E)Suction the nares.
      F)Apply urine collection bag.
      G)Obtain blood cultures.
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    Exam Review

    1. A nurse is assisting in the care of a client on the medical-surgical unit. Which of the following client findings suggest that the nurse should hold the tube feeding and notify the provider? Select all that apply.(SATA)
      A)Laboratory electrolyte levels
      B)Oxygen saturation
      C)Abdominal findings
      D)Blood glucose
      E)Gastric residual
      F)pH of gastric contents
    2. A charge nurse is supervising a newly licensed nurse who is caring for a client who is experiencing auditory hallucinations and is refusing medication. The newly licensed nurse suggests placing the medication in the client's food to the charge nurse. Which of the following actions should the charge nurse take?
      A)Suggest the family persuade the client to take the medication.
      B)Recommend that the medication be delivered intramuscularly.
      C)Remind the newly licensed nurse that the client has a right to refuse medication.
      D)Suggest the newly licensed nurse contact the pharmacy to inquire about compatible foods.
    3. A nurse from a medical-surgical unit is floating to a postpartum unit. Which of the following clients is an appropriate assignment for the nurse to accept?
      A)A client who had a cesarean delivery 24 hr ago
      B)A client who is receiving oxytocin for uterine atony
      C)A client who will be breastfeeding for the first time
      D)A client who underwent removal of a retained placenta
    4. A nurse is applying a condom catheter to a male client who is incontinent. Which of the following is an appropriate technique to use?
      A)Apply sterile gloves after performing hand hygiene.
      B)Unroll the catheter before applying it to the penis.
      C)Leave space between the tip of the penis and the end of the condom catheter.
      D)Tape the condom catheter to the penis using waterproof adhesive tape.
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    Exam Review

    1. A nurse is reviewing the list of medications for a client who has a new prescription for fluoxetine. The nurse should identify that which of the following medications is contraindicated with fluoxetine?
      A)Prednisolone
      B)Lispro
      C)Calcitonin
      D)Phenelzine
    2. A nurse is preparing to administer purified protein derivative (PPD) to a client. The nurse should use which of the following routes?
      A)Subcutaneous
      B)Intramuscular
      C)Intradermal
      D)Oral
    3. A nurse is caring for a client who is receiving morphine 2 mg subcutaneously every 4 hr for pain. The medication is available in a vial containing 10 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
    4. A nurse is discussing ethical principles with a newly licensed nurse. Which of the following actions should the nurse identify as demonstrating veracity?
      A)Avoiding actions that can cause harm to the client
      B)Prioritizing interventions that benefit the client
      C)Allowing the client to function independently
      D)Being honest with the client
    Page 3 of 45

    Exam Review

    1. A nurse is reinforcing teaching about bottle feeding techniques with the guardian of a newborn. Which of the following statements by the guardian indicates an understanding of the teaching?
      A)"The feeding should last 5 to 10 minutes."
      B)"My baby should be burped prior to feeding."
      C)"My baby might spit up a small amount of formula while feeding."
      D)"The opening of the nipple should be enlarged."
    2. A nurse is reinforcing teaching with an adolescent who has a new prescription for cefazolin. For which of the following findings should the nurse instruct the adolescent to monitor and report to the provider?
      A)Constipation
      B)Elevated skin patches
      C)Ringing in the ears
      D)Depression
    3. A nurse is reinforcing teaching about the purpose of quadruple screening for a client who is at 16 weeks of gestation. Which of the following statements should the nurse make?
      A)"This test identifies indicators for birth defects."
      B)"This test determines the sex of the fetus."
      C)"This test screens for gestational diabetes,"
      D)"This test diagnoses fetal infection."
    4. A nurse is collecting data from an 18-month-old toddler at a well-child visit. Which of the following findings should the nurse report to the provider?
      A)The toddler can remove her own socks.
      B)The toddler has a security blanket.
      C)The toddler can say four words.
      D)The toddler throws a ball without falling.
    Page 4 of 45

    Exam Review

    1. A nurse is preparing to perform a physical examination for a 16-year-old adolescent. Which of the following actions should the nurse plan to take?
      A)Encourage the parents to remain in the room.
      B)Avoid using medical terminology during the examination.
      C)Allow the adolescent to handle the equipment.
      D)Limit the adolescent's choices throughout the examination
    2. A nurse is planning to administer an ophthalmic medication to a client. Which of the following actions will minimize systemic absorption of the medication?
      A)Apply light pressure to the inner canthus just after instilling the eye drops.
      B)Wipe the eye from the inner to the outer canthus with a sterile saline-moistened cotton ball.
      C)Administer the medication drops directly into the lower conjunctival sac of each eye.
      D)Wait 5 min after instillation before instilling the drops in the other eye.
    3. A nurse is caring for a female client who has a new diagnosis of breast cancer. The client is concerned about potential changes to her body image depending on her choice of treatment. Which of the following actions should the nurse take?
      A)Reassure the client that she will adjust to changes to her body.
      B)Contact an occupational therapist to talk with the client.
      C)Initiate a client referral to Reach to Recovery.
      D)Explain that surgery can restore the breast to its original appearance.
    4. A nurse is reviewing standard precautions with an assistive personnel (AP) who is new to the newborn nursery. For which of the following newborn care procedures should the nurse remind the AP to wear clean gloves?
      A)Removing a mask after phototherapy
      B)Applying an identification bracelet
      C)Measuring axillary temperature
      D)Changing wet diapers
    Page 5 of 45

    Exam Review

    1. A nurse is performing a nutritional screening for a client. Which of the following statements by the client indicates the need for further data collection?
      A)"I eat at least two meals every day and snack frequently."
      B)"I drink 4 ounces of wine with dinner several times each week."
      C)"I take several prescription medications every day."
      D)"I am able to keep my weight steady without gaining or losing."
    2. A nurse is preparing to instill an otic suspension into an adult client's ear. Which of the following methods should the nurse plan to use?
      A)Pull the auricle upward and outward.
      B)Pull the auricle downward and backward.
      C)Pull the auricle upward and backward.
      D)Pull the auricle downward and outward.
    3. A nurse is calculating the intake for a client who reports eating a 4 oz container of ice cream and drinking 8 oz of coffee. The nurse should document how many mL of fluid intake in the client's medical record? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
    4. A nurse is preparing to transfer a client who has left-sided weakness from the bed to a wheelchair. Which of the following actions should the nurse take first?
      A)Position the seat of the wheelchair at a right angle to the bed.
      B)Lock the wheels on the bed.
      C)Have the client sit at the edge of the bed.
      D)Place a gait belt around the client's waist.
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