Exam Review

A nurse is teaching a parent of a-month-old infant about home safety. Which of the following instructions should the nurse include in the teaching?( select all that apply)
(SATA)
A)
place gate at the top and bottom of the stairs.
B)
Ensure the crib mattress is in the lowest position.
C)
Remove labels from containers that contain toxic substance.
D)
Keep toilet lids in the upright position.
E)
select a toy chest that has a heavy, hinged lid.
What should a nurse include in a nutrition class for pregnant teenagers? Choose all that apply.
(SATA)
A)
Increase daily caloric intake by 300 to 400 calories.
B)
Consume folic acid supplements daily.
C)
Maintain current protein intake.
D)
Take daily iron and calcium supplements.
E)
Limit weight gain to no more than 15 pounds (6.8 kg) during pregnancy.
A nurse is managing the care of a female client with an ileostomy who has been experiencing complications and has recently undergone a stoma revision. The client’s condition is evolving over several days, and the nurse is reviewing all relevant exhibits to assess the need for further intervention. Exhibits Based on the exhibits provided, which findings require immediate intervention by the nurse? Select all that apply.
(SATA)
A)
The stoma has a bluish discoloration and is bleeding extensively.
B)
The skin surrounding the stoma has large open sores with oozing.
C)
The client is exhibiting a temperature of 37.8°C (100.0°F).
D)
The client has a heart rate of 90 beats per minute.
E)
The client reports increased nausea and vomiting.
F)
The stoma culture is negative for mixed bacteria.
G)
The client refuses to participate in stoma care education.
A nurse is caring for a 68-year-old male client in the accident and emergency department. The client was brought in by his daughter after he fell at home. Exhibits The nurse should anticipate which of the following interventions?
A)
Administer oxygen at 2 L/min via nasal cannula.
B)
Prepare the client for immediate surgery.
C)
Apply a cold pack to the client’s right hip.
D)
Assist the client to a standing position and assess his ability to bear weight on the right leg.

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Exam Review

The same nurse is now preparing to clean the abrasion on the client’s right elbow. The provider has prescribed mechanical debridement for the wound. Exhibits Which of the following is a form of mechanical debridement that the nurse should expect to use?
A)
Wet-to-dry dressings
B)
Surgical debridement
C)
Enzymatic debridement
D)
Autolytic debridement
A nurse is caring for a 68-year-old male client who was admitted to a rehabilitation unit following a repair of a right hip fracture. The client has limited mobility and requires assistance to turn and transfer out of bed. It’s Day 4, 0700hrs. Exhibits The client is at greatest risk for developing ▾ Pressure ulcer due to ▾ Limited mobility.
Dropdown 1:
Option 1: Dehydration
Option 2: Infection
Option 3: Pressure ulcer
Option 4: Hypocalcemia
Dropdown 2:
Option 1: Limited mobility
Option 2: Calcium level of 9.0 mg/dL
Option 3: Urinary incontinence
Option 4: Dry and intact dressing
A nurse is about to replace a nearly depleted container of total parenteral nutrition (TPN) for a patient, but discovers a delay in the delivery of the new TPN solution from the pharmacy. Which solution should the nurse administer until the next TPN solution is available?
A)
0.9% sodium chloride.
B)
Dextrose 10% in water.
C)
3% sodium chloride.
D)
Lactated Ringer’s.
A nurse is educating a patient who recently had a colostomy. What information should the nurse include in the teaching?
A)
The stoma may appear purplish during the first week.
B)
A small amount of bleeding around the stoma is normal.
C)
Fecal output can be expected within 24 hours.
D)
An increase in the intake of raw vegetables is necessary.

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Exam Review

A nurse finds that the infusion pump for a patient’s total parenteral nutrition (TPN) solution is not working. What condition should the nurse monitor the patient for?
A)
Excessive thirst and urination.
B)
Shakiness and diaphoresis.
C)
Fever and chills.
D)
Hypertension and crackles.
A nurse is caring for a patient with methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound and is about to check the patient’s pulse. What precautions should the nurse take?
A)
Wear sterile gloves.
B)
Wear protective eyewear.
C)
Wear clean gloves.
D)
Wear an N95 respirator mask.
A nurse is preparing a preoperative patient for a sigmoid colostomy. What information should the nurse include in the discussion?
A)
The stoma will be located in the lower left abdomen.
B)
The stoma may appear purple.
C)
The colostomy will not produce formed stool.
D)
The end of the stoma may be painful after the procedure.
A nurse is providing skin care for a patient with urinary incontinence. What actions should the nurse take?
A)
Use soap to clean the patient’s skin.
B)
Apply a barrier cream to the patient’s skin.
C)
Avoid applying friction when drying the patient’s skin.
D)
Use warm water to clean the patient’s skin.

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Exam Review

A nurse is reviewing urinary laboratory results. Which findings should prompt the nurse to follow up?
A)
Specific gravity of 1.036.
B)
pH of 6.4.
C)
Presence of proteinuria.
D)
Presence of hematuria.
A nurse is caring for a patient with a nasogastric (NG) tube and tests the pH of the secretions to verify correct placement of the tube. What pH reading should the nurse expect?
A)
70.
B)
40.
C)
60.
D)
80. .
A nurse is assessing a client who has a colostomy and notices that the stoma is pale in color. Which of the following findings should the nurse report to the provider?
A)
The skin around the stoma is red.
B)
The ostomy is draining frequently.
C)
The stool is yellow-green.
D)
The stoma is moist and pink.
A nurse is inserting a catheter into a female patient. When the nurse inserts the catheter, no urine is obtained. The nurse suspects the catheter is not in the urethra. What should the nurse do?
A)
Fill the balloon with the recommended sterile water.
B)
Remove the catheter, wipe with alcohol, and reinsert after lubrication.
C)
Leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter.
D)
Discard the catheter and begin again.

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Exam Review

A nurse is teaching a client who is preoperative for an ileostomy. Which of the following statements should the nurse include?
A)
You will have a stoma placed in your right lower abdomen.
B)
The end of the stoma will be painful after this procedure.
C)
You should expect your stoma to be a purple color.
D)
You will have solid stool pass through your stoma.
A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material?
A)
Discard the dressing in the bedside trash receptacle.
B)
Double-bag the dressing in clear bags and label it “biohazard”.
C)
Enclose the dressing in a single clear plastic bag and discard in the bedside trash receptacle.
D)
Dispose of the dressing in a biohazardous waste container.
A nurse is teaching a client who has urinary incontinence about avoiding foods and beverages that can cause bladder irritation.Which of the following foods and beverages is a bladder irritant?
A)
Fresh vegetables
B)
Red meat
C)
Dairy products
D)
Caffeinated beverages
A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?
A)
Mix the three medications together prior to administering.
B)
Maintain the head of the bed in a flat position for 30 min following medication administration.
C)
Flush the NG feeding tube with 30 mL of water immediately following medication administration.
D)
Dilute each medication with 10 mL of tap water.

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Exam Review

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan to take?
A)
Don sterile gloves before inserting the indwelling urinary catheter.
B)
Apply an oil-based lubricant to the indwelling urinary catheter.
C)
Use one cotton swab to clean the client’s genitalia.
D)
Test the balloon on the indwelling urinary catheter before insertion.
A nurse is preparing to obtain a 24-hour urine collection from a client. Which of the following actions should the nurse plan to take?
A)
Refrigerate the urine during the collection time period.
B)
Discard the client’s last void at the end of the collection time period.
C)
Include toilet paper with the collected urine.
D)
Save the first void at the start of the collection time period.
A nurse is evaluating a nursing assistive personnel’s (AP) care for a patient with an indwelling catheter. Which action by the AP will cause the nurse to intervene?
A)
Emptying the drainage bag when half full.
B)
Placing the drainage bag on the side rail of the patient’s bed.
C)
Kinking the catheter tubing to obtain a urine specimen.
D)
Securing the catheter tubing to the patient’s thigh.
Which of the following correctly describes the process of hearing?
A)
Vibration of the eardrum is directly transmitted to the eighth cranial nerve, bypassing the inner ear structures.
B)
Sound waves enter the ear canal and are converted to electrical impulses.
C)
Vibration of the eardrum transmits through the bony ossicles to the perilymph in the inner ear, stimulating the eighth cranial nerve.
D)
Sound is transmitted directly from the eardrum to the brain.

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