Exam Review

A nurse in a long-term care facility is caring for a client who is upset over not being able to find their spouse, who passed away years ago. Which of the following actions should the nurse take first?
A)
Administer alprazolam to the client to decrease their anxiety.
B)
Take the client for a walk outdoors and ask them to talk about their family.
C)
Take the client to their room so they will not upset other clients.
D)
Administer haloperidol to the client to decrease their agitation.
A nurse is planning care for a client who reports heartburn. Which of the following tests should the nurse anticipate in the client's plan of care?
A)
Colonoscopy
B)
Flexible sigmoidoscopy
C)
Lower GI series
D)
Upper GI endoscopy
A nurse is preparing to administer a client's antihypertensive medication. When using clinical judgment, which of the following findings indicates the nurse should collect further data from the client before administering medication?
A)
The client reports dizziness when ambulating to the bathroom.
B)
The client reports having trouble sleeping the previous night.
C)
The client has a urine output of 400ml for the past 8 hr
D)
The client ate 60% of their breakfast
A patient with a history of angina pectoris reports chest discomfort described as tightness and pressure radiating to jaw and left arm during mild exertion, relieved by rest. Based on this clinical presentation and the pathophysiology of angina, which of the following nursing actions are appropriate to prioritize?
(SATA)
A)
Administer sublingual nitroglycerin as prescribed to relieve acute chest pain
B)
Prepare to administer intravenous nitroglycerin immediately in all angina cases
C)
Monitor for pain relief within 5 to 10 minutes after nitroglycerin administration to evaluate treatment effectiveness
D)
Encourage the patient to rest and avoid exertion until symptoms resolve
E)
Assess for associated symptoms such as diaphoresis, nausea, and shortness of breath
F)
Instruct the patient to take aspirin only if chest pain is severe and lasts over 15 minutes

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Exam Review

A nurse is reinforcing teaching with a newly licensed nurse about a nonrebreather mask. Which of the following instructions should the nurse include?
A)
Use a nonrebreather mask to deliver low-flow oxygen.
B)
A nonrebreather mask should fit snugly over a client's face.
C)
The reservoir bag on a nonrebreather mask should collapse with exhalation.
D)
A nonrebreather mask dries a client's mucous membranes.
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)
Apply an oil-based lubricant to the indwelling urinary catheter.
B)
Use one cotton swab to clean the client's urinary meatus.
C)
Don sterile gloves before inserting the indwelling urinary catheter.
D)
Test the balloon on the indwelling urinary catheter before insertion.
A nurse is teaching a client about the purpose of a fecal occult blood test (FOBT). Which statement by the client demonstrates correct understanding of why this test is performed?
A)
It detects blood in my stool that I might not see but could indicate colon problems.
B)
It helps identify bacterial infections in my stool such as Clostridioides difficile.
C)
It detects visible blood in stool to confirm bleeding from hemorrhoids.
D)
It measures the amount of iron in my blood to assess anemia.
A nurse is preparing to insert an indwelling urinary catheter in a male patient. Which action demonstrates the correct procedure for cleansing the penis before catheter insertion to minimize infection risk?
A)
Cleanse the penis with soap and water without retracting the foreskin, then insert the catheter immediately.
B)
Use povidone-iodine to clean only the shaft of the penis without exposing the glans or meatus.
C)
Retract the foreskin if uncircumcised, cleanse the glans penis with povidone-iodine using a sterile swab, then release the foreskin after catheter insertion.
D)
Apply bacitracin ointment to the meatus before catheter insertion to prevent infection.

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Exam Review

A nurse is planning care for clients. Which of the following tasks can the nurse delegate to an assistive personnel (AP)?
A)
Providing tracheostomy care for a client.
B)
Obtaining a blood pressure for a client who is to be discharged later in the day.
C)
Collecting data on a client who just returned from surgery.
D)
Reinforcing teaching to a client who is preoperative how to use an incentive spirometer.
A nurse is collecting data from a client who has an inadequate dietary intake of omega-3 fatty acids. Which of the following findings should the nurse expect?
A)
Bleeding gums
B)
Constipation
C)
Brittle hair
D)
Memory loss
A nurse in an urgent care facility is assisting in performing triage on a group of clients. Which of the following clients should the nurse recommend be seen first?
A)
A client who has a new onset of atrial fibrillation and a heart rate of 152/min.
B)
A client who reports urinary burning and a temperature of 39.2° C (102.5° F).
C)
A client who has cirrhosis of the liver and bruising on their arms.
D)
A client who has heart failure and peripheral edema.
A nurse is delegating care for a group of four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
A)
Obtain a daily weight on a client who has heart failure.
B)
Administer oral PRN pain medication to a client who has arthritis.
C)
Reinforce teaching the use of an incentive spirometer to a postoperative client.
D)
Irrigate and perform a dressing change for a client who has a pressure injury wound.

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Exam Review

A nurse is teaching a client who is on a low sodium diet. Which of the following instructions should the nurse include?
A)
Read labels on foods before eating.
B)
Limit intake of canned soups to 2 servings.
C)
Replace fresh meats with processed meats.
D)
Choose bottled salad dressings.
A nurse is preparing to obtain a sputum specimen for a client. Which of the following actions should the nurse plan to take?
A)
Rinse the client's mouth before collecting the specimen.
B)
Obtain the specimen from the client in the evening.
C)
Save the sputum specimen in a clean container.
D)
Collect the sputum specimen after a meal.
A nurse is collecting data on a client who is receiving intermittent enteral nutrition through a nasogastric tube. Which of the following findings is the nurse's priority?
A)
The client reports being thirsty.
B)
The client is regurgitating the enteral formula.
C)
The client is experiencing abdominal cramping.
D)
The client is reporting constipation.
A nurse is preparing to administer acetaminophen 10/mg/kg PO to a preschool child for fever. The child weighs 22 lb. Available is acetaminophen liquid 160 mg/5 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.)

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Exam Review

A nurse is assisting with the care of a client who has a chest tube. Which of the following actions should the nurse take?
A)
Tape the connections on the client's chest tube.
B)
Strip the client's chest tube every 2 hrs.
C)
Loop the tubing of the chest tube on the client's bed.
D)
Place the chest tube drainage system above the level of the client's heart.
A nurse is working with an RN to admit a new client. Which of the following steps of the nursing process is the nurse using when assisting to formulate goals for a positive outcome?
A)
Implementation
B)
Evaluation
C)
Planning
D)
Data collection
A nurse is providing catheter care for a female client with an indwelling urinary catheter. Which action demonstrates the best practice to prevent catheter- associated urinary tract infections (CAUTIs)?
A)
Performing catheter care once every 24 hours during routine bathing
B)
Using alcohol-based wipes for cleansing the catheter and surrounding area
C)
Cleaning the urethral meatus first, then cleaning down the catheter away from the body while holding the catheter near the meatus to avoid tension
D)
Pulling the catheter gently during cleaning to fully expose the meatus for better hygiene
Which of the following is a component of clinical decision-making that the nurse should use to make an evidence-based decision?
A)
Clinical judgement
B)
Clinical reasoning
C)
Critical thinking
D)
Concept mapping

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Exam Review

A nurse is reviewing morning laboratory reports for clients on the unit. The nurse should recognize that which of the following laboratory findings is the priority to report to the provider?
A)
A client who has an INR of 5.2.
B)
A client who has a BUN of 21 mg/dL.
C)
A client who has a hemoglobin of 19 g/dL.
D)
A client who has a fasting glucose level of 69 mg/dL.
A nurse is collecting data on a client who has mitral valve stenosis. Which of the following findings should the nurse expect?
A)
Clubbing of the fingers
B)
Barrel chest
C)
Bradycardia
D)
Heart murmur
A nurse is preparing to administer an enema to a client. Which of the following actions should the nurse plan to take?
A)
Place the client into a right lateral position.
B)
Use sterile technique.
C)
Lubricate the tubing with an oil-based lubricant.
D)
Warm the enema solution to room temperature.
A nurse is planning to insert a female external urinary catheter for a client. Which of the following actions should the nurse plan take?
A)
Insert the catheter into the client's urethra.
B)
Connect the catheter to continuous wall suction.
C)
Replace the external urinary catheter once each day.
D)
Apply a barrier cream to the client's perineal skin

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