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    Exam Review

    1. A nurse is teaching a client who has a new prescription for colchicine to treat gout. Which of the following instructions should the nurse include?
      A)
      "Monitor for muscle pain.
      B)
      "Expect to have increased bruising
      C)
      "Increase your intake of grapefruit juice."
      D)
      "Take this medication with food if nausea develops
    2. Which of the following actions by a nurse can help reduce a client's anxiety related to medication administration? (Select all that apply)
      (SATA)
      A)
      Forcing the client to take the medication
      B)
      Ignoring the client's concerns about the medication
      C)
      Explaining the potential adverse effects of the medication
      D)
      Allowing the client to ask questions about the medication
      E)
      Administering medication without any prior explanation
      F)
      Verifying the client's understanding of the medication
    3. A nurse is providing teaching to a client who has renal failure and an elevated phosphorous level. The provider instructed the client to take aluminium hydroxide 300 mg PO three times daily. For which of the following adverse effects should the nurse inform the client?
      A)
      Muscle spasms
      B)
      Constipation
      C)
      Headache
      D)
      Metallic taste
    4. A nurse is implementing a bladder retraining program for a client. Which of the following actions should the nurse take?
      A)
      Restrict oral fluid intake during waking hours.
      B)
      Encourage the client to hold her breath when feeling the urge to urinate
      C)
      Assist the client to the bathroom every 2 hr.
      D)
      Provide adult diapers until bladder retraining is successful
    Page 1 of 24

    Exam Review

    1. A nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?
      A)
      Carotid
      B)
      Brachial
      C)
      Popliteal
      D)
      Femoral
    2. A nurse is preparing to administer a pre-packaged oral medication to a client and complete the final medication check. At which of the following times or places should the nurse perform this final check?
      A)
      In the area where the nurse obtained the Dedication
      B)
      At the nurses' station while reviewing the provider's prescription
      C)
      At the time of documentation
      D)
      At the client's bedside before administration
    3. During an abdominal assessment, which of the following findings would be considered abnormal and warrant further investigation? (Select all that apply)
      (SATA)
      A)
      Soft and symmetrical abdomen
      B)
      Prominent venous patterns with dilated veins
      C)
      Тympanic upon percussion of the abdomen
      D)
      Positive rebound tenderness
      E)
      Centrally located and inverted umbilicus
      F)
      Hyperactive bowel sounds in all quadrants
    4. Which of the following is the most important safety precaution to take when administering enteral feeding to a patient?
      A)
      Check the expiry date of the feeding formula
      B)
      Flush the tube with water before and after feeding
      C)
      Ensure the feeding tube is correctly positioned before starting the feeding
      D)
      Administer the feeding at room temperature
    Page 2 of 24

    Exam Review

    1. A nurse is caring for a client who has a new diagnosis of chronic kidney disease. Which of the following statements should the nurse identify as an Indication of anticipatory grieving?
      A)
      "I just can't believe that this dialysis is going to ruin my whole life."
      B)
      “I know that kidney disease runs in my family, but I can prevent it."
      C)
      "I can now eat whatever I want. The dialysis will remove it from my system."
      D)
      “I know that I will get a kidney transplant. I am a good candidate,"
    2. A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?
      A)
      "A client's address would be an example of personally identifiable information."
      B)
      "HIPAA is a federal law, not a state law.
      C)
      "Information about a client can be disclosed to family members at any time."
      D)
      “HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form.”
    3. A nurse is teaching a client how to draw up regular insulin and NPH insulin into the same syringe. Which of the following instructions should the nurse include?
      A)
      Shake the NPH insulin until it is well mixed.
      B)
      Draw up the NPH insulin into the syringe first.
      C)
      Inject air into the regular insulin first.
      D)
      Discard regular insulin that appears cloudy.
    4. A nurse is caring for a client on a medical-surgical unit. Exhibits Click to highlight the documentation in the client's medical record that requires further action by the nurse. To deselect a finding, click on the finding again. 0830 Client assessment performed. Heart rate 102/min Respiratory rate 20/min Breath sounds clear and equal bilaterally Blood pressure 128/66 mm Hg Temperature 38.9°C (102°F) Oxygen saturation 95% on room air Abdomen soft, nondistended with hyperactive bowel sounds audible in 4 quadrants. Hematocrit 47% (37% to 47%) Hemoglobin 16 g/dL (12 g/dL to 16 g/dL) Potassium 3.3 mEq/L (3.5 to 5.0 mEq/L)
      A)
      Heart rate 102/min
      B)
      Temperature 38.9°C (102°F)
      C)
      Abdomen soft, nondistended with
      D)
      hyperactive bowel sounds audible in 4 quadrants
      E)
      Hematocrit 47% (37% to 47%)
      F)
      Hemoglobin 16 g/dL (12 g/dL to 16 g/dL)
      G)
      Potassium 3.3 mEq/L (3.5 to 5.0 mEq/L)
    Page 3 of 24

    Exam Review

    1. A nurse is preparing to administer amoxicillin 350 mg PO. Available is amoxicillin 250 mg/5 mL. How many mL should the nurse administer? (Round to the nearest whole number.)
    2. A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply)
      A)
      Distended bladder
      B)
      Dysuria
      C)
      Tenderness over the symphysis pubis
      D)
      Voiding 30 mL frequently
      E)
      Report of feeling pressure
    3. A nurse is reviewing a client's laboratory report of arterial blood gas (ABG) findings: pH 7.28, HCO, 18 mEq/L, and PaCO, 36 mm Hg. Which of the following conditions should the nurse anticipate when interpreting these findings?
      A)
      Metabolic acidosis
      B)
      Metabolic alkalosis
      C)
      Respiratory acidosis
      D)
      Respiratory alkalosis
    4. A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?
      A)
      Hyperventilate the client on 100% oxygen prior to suctioning
      B)
      Lubricate the suction catheter tip with sterile saline.
      C)
      Perform chest physiotherapy prior to suctioning
      D)
      Suction two to three times with a 60-second pause between passes.
    Page 4 of 24

    Exam Review

    1. A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?
      A)
      Secure the restraints to the lowest bar of the side rail.
      B)
      Secure the restraints using a quick-release tie
      C)
      Anticipate removing the restraints every 4 hr.
      D)
      Ensure four fingers fit under the restraints to prevent constriction
    2. A nurse is caring for a client in a geriatric unit. Exhibits For each client finding below, indicate if the finding is a best practice for managing enteral feeding tube safety or potential risk. Each finding may be associated with more than one category.
      A)
      Ignoring cuff pressure during feeding
      B)
      Checking tube placement before each feeding
      C)
      Head of bed elevation at 30 degrees
      D)
      Monitoring for signs of aspiration
    3. A nurse is implementing a bowel training program for a client. For the program to be effective, the nurse should take the client to the toilet at which of the following times?
      A)
      When the client has the urge to defecate
      B)
      After the client feels abdominal cramping
      C)
      Every 2 hr while the client is awake
      D)
      Immediately before the client has a meal
    4. A nurse is assisting a provider with a sterile procedure and prepares to pour solution onto a piece of sterile gauze. In what order should the nurse perform the following steps when pouring sterile solution? (Move the steps on the left into the box on the right, placing them in the selected order. of performance. Use all the steps.)
      A)
      Pour the solution onto the gauze.
      B)
      Place the bottle cap face-up on a clean surface.
      C)
      Perform hand hygiene.
      D)
      Pick up the bottle with the label facing toward the palm.
      E)
      Pour 1 to 2 mL into a receptacle.
      F)
      Remove the bottle cap.
    Page 5 of 24

    Exam Review

    1. A patient is learning to use the three-point gait with crutches. Which action indicates they have mastered this technique?
      A)
      They advance both crutches forward, then the unaffected leg
      B)
      They keep the affected leg slightly touching the ground for balance
      C)
      They alternate weight between both feet and crutches.
      D)
      They lean forward while advancing the affected leg
    2. A nurse is caring for a client in a surgical recovery unit. Exhibits Drag the words from the choices below to fill in each blank in the following sentence To effectively conduct an abdominal assessment, a nurse shoulddropdown, dropdownand dropdownin the correct order
    3. Which of the following best describes the 4-point gait pattern?
      A)
      Advancing one crutch and the opposite leg simultaneously.
      B)
      Moving both crutches forward followed by moving both legs together.
      C)
      Advancing both crutches then hopping forward on the unaffected leg
      D)
      Advancing each crutch separately followed by the opposite leg
    4. A nurse is teaching a client who has a new prescription for aluminum hydroxide to treat heartburn. The nurse should instruct the client to monitor for and report which of the following adverse reactions?
      A)
      Flatulence
      B)
      Constipation
      C)
      Palpitations
      D)
      Headache
    Page 6 of 24