Exam Review

A nurse is assessing a client's ability to ambulate with crutches using a three-point gait. Which of the following actions should the nurse identify as a risk to the client's safety?
A)
The client pushes downward on the handgrips
B)
The client stands in a tripod position prior to walking
C)
The Client places partial weight on the affected leg
D)
The client keeps the elbows in a fixed position
A patient is admitted with a stroke. The outcome of this disorder is uncertain, but the patient is unable to move the right arm and leg. The nurse starts passive range-of-motion (ROM) exercises. Which finding Indicates successful goal achievement?
A)
Contractures developed.
B)
Muscle strength improved.
C)
Heart rate decreased
D)
joint mobility maintained
A nurse is providing range of motion (ROM) for a patient with impaired mobility. Which technique will the nurse use for each movement?
A)
Each of movement is repeated 5 times by the patient
B)
Each movement is moved just to the point of resistance by the nurse
C)
Each movement is completed quickly and smoothly by the nurse
D)
Each movement is performed until the patient’s reports pain
The nurse is caring for a patient who has been trying to quit smoking. The patient has been smoke free for 2 weeks but had two cigarettes last night and at least two this morning, what should the nurse anticipate?
A)
The patient must pick up the attempt right where the patient left left off
B)
The patient will need to adapt a new lifestyle for change to be effective
C)
The patient does not want and will never quit smoking
D)
The patient will return to the contemplation or precontemplation phase

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Exam Review

A nurse is reviewing the medical record for a client who has a health care-associated infection (HAI). The nurse should identify which of the following findings as a risk factor for acquiring an HAI?
A)
The client is a male.
B)
The client is 71 years old.
C)
The client had an appendectomy 6 months ago.
D)
The client has bipolar disorder.
A nurse is providing health promotion teaching to an adolescent. Which of the following information should the nurse include in the teaching?
A)
Tanning beds are much safer then lying in the sun.
B)
"Share piercing needles only with close friends you trust."
C)
Your need for sleep will increase during periods of growth."
D)
"Limit your caloric intake to avoid becoming overweight."
The nurse is preparing a smoking cessation class for family members of patients with lung cancer. The nurse believes that the class will convert many smokers to nonsmokers once they realize the benefits of not smoking, Which health care model is the nurse following?
A)
Health promotion model
B)
Maslow's hierarchy of needs
C)
Health belief model
D)
Holistic health model
The nurse is assessing the patient for respiratory complications of immobility. Which action will the nurse take assessing, the respiratory system?
A)
Auscultate the entire lung region to assess lung sounds
B)
Assess the patient at least every 4 hours.
C)
Inspect chest wall movements primarily during the expiratory cycle
D)
Focus auscultation on the upper lung fields

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Exam Review

A nurse is supervising the logrolling of a patient. To which patient is the nurse most likely providing care?
A)
A patient with a stage IV pressure ulcer
B)
A patient with neck surgery
C)
A patient with hypostatic pneumonia
D)
A patient with a total knee replacement
A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
A)
"I will place an area rug at the entry of my bathroom.
B)
I will keep the fluorescent ceiling light on in my room at night."
C)
I will place a bath seat in my shower to use when I bathe.
D)
"I will keep my walker at the end of my bed.
A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? (Select all that apply.)
A)
Assess the client every 4 hr.
B)
Keep the client's room dark at night.
C)
Teach the client to use the call light.
D)
Keep the client's bed in the lowest position
E)
Place a fall-risk identification band on the client's wrist
A patient is admitted to a rehabilitation facility following stroke. The patient has right-sided paralysis and is unable to speak. The patient will be receiving physical therapy and speech therapy. Which level of preventive care is the patient receiving?
A)
Tertiary prevention
B)
Primary prevention
C)
Health Promotion
D)
Secondary prevention

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Exam Review

A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse plan to include in the plan? (Select all that apply)
A)
Place the bedside table within the client's reach.
B)
Teach balance and strengthening exercises.
C)
Provide information about home safety checks.
D)
Administer sedative at bedtime.
E)
Lock beds and wheelchairs when not providing care.
A group of nurses are discussing risk factors for transmission of human immunodeficiency virus (HIV) from clients: Which of the following individuals should the nurse identify as being at the greatest risk for contracting HIV?
A)
A nurse who works for an insurance company and collects urine samples from clients who have HIV
B)
A personal trainer who works with a client who has HIV
C)
A phlebotomist who collects blood from clients who have HIV
D)
An occupational therapist who works with a client who has HIV
A nurse manager is observing the care provided by a nurse who is in orientation to the unit. Which of the following actions by the nurse indicates the nurse manager should intervene?
A)
The nurse opens the top flap of a sterile tray toward the body when assisting the provider with a thoracentesis.
B)
The nurse uses clean gloves when discontinuing a client's intravenous infusion.
C)
The nurse uses the client's telephone number as one form identification when administering medications to a client.
D)
The nurse empties client's drainable colostomy pouch when it is one third full.
A nurse is preparing a community health program for adults at risk for cardiovascular disease. Which of the following should the nurse include as a modifiable risk factor?
A)
Diagnosis of diabetes mellitus
B)
Family history of cardiac disease
C)
Increasing age
D)
Cigarette smoking

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Exam Review

A nurse is preparing a sterile field. Which of the following actions should the nurse perform when opening the sterile pack?
A)
Reach around the pack and open the top flap away from the body.
B)
Move to the opposite side of the pack to open the fourth flap.
C)
Place the pack on a sterile work surface.
D)
Open the right flap with the left hand.
A nurse is using Maslow's hierarchy to prioritize care for an anxious patient that is not eating and will not see family members. Which area should the nurse address first?
A)
Anxiety
B)
Not seeing family members
C)
Not eating
D)
Mental Health
A nurse is assessing the body alignment of a standing patient. Which finding will the nurse report as normal?
A)
When observed posteriorly, the hips and shoulders form an ‘’S’’ pattern
B)
When observed laterally, the spinal curves align in a reversed S pattern
C)
the arms should be crossed over the chest or in the lap
D)
LThe feet should be close together with toes pointed out
A nurse is teaching a health promotion class about isotonic exercises. Which types of exercises will the nurse give as examples?
A)
Quadriceps set exercises and contraction of the gluteal muscles
B)
Swimming, jogging, and bicycling
C)
Tightening or tensing of muscles without moving body parts
D)
Push-ups, hip lifting, pushing feet against a footboard on the bed

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Exam Review

A nurse is following the goals of Healthy People 2030 to provide care. Which action should the nurse take?
A)
Promoting a society in which people live long healthy lives.
B)
Allowing people to continue current behaviors to reduce the stress of change.
C)
Focusing on illness treatment to provide fast recuperation
D)
Focusing only on health changes that will lead to better local communities:
A client smoking in his bathroom has dropped a cigarette butt into wastepaper basket, which begins to smolder. Which of the following actions is the nurse's priority?
A)
Activate the fire alarm.
B)
Move any clients in the immediate vicinity.
C)
Close the fire doors on the unit.
D)
Use a fire extinguisher to put out the fire.
While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the first?
A)
Complete an incident report.
B)
Request the risk manager obtain consent for HIV testing from the client.
C)
Consent to postexposure treatment with antiretroviral medications.
D)
Wash the site of injury with soap and water.
The nurse is caring for a patient with impaired physical mobility. Which potential complications will the nurse monitor for in this pi(Select All that Apply.)
A)
Foot drop
B)
Increased socialization
C)
Somnolence
D)
Hypostatic pneumonia
E)
Impaired skin intergrity

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