Exam Review

A nurse is reinforcing teaching with a client who is taking hydrochlorothiazide. Which of the following information should the nurse include in the teaching?
A)
Take the medication on an empty stomach.
B)
Take the medication at bedtime.
C)
Muscle weakness is an expected adverse effect.
D)
Increase daily intake of foods high in potassium.
What is a crucial consideration when preparing a patient for an electrocardiogram (EKG/ECG)?
A)
Instructing the patient to fast for at least 12 hours before the procedure
B)
Ensuring the skin is clean and dry where electrodes will be placed
C)
Using a higher room temperature to keep the patient warm
D)
Applying electrodes directly over bony prominences
A nurse is reinforcing health screening education with a group of clients. The nurse should recognize that which of the following clients has the greatest risk for hypertension?
A)
A client who is of Asian ethnicity
B)
A female client who is 44-years-old
C)
A client who is African American
D)
A male client who is 53-years-old
Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?
A)
Obtain a pair of slipper socks for the client.
B)
Place a moist heating pad under the client's feet.
C)
Rub the client's feet briskly for several minutes.
D)
Increase the client's oral fluid intake.

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Exam Review

A nurse is caring for a client who has an acute respiratory illness. For which of the following manifestations of an airway obstruction should the nurse monitor? (Select all that apply.)
(SATA)
A)
Cyanosis
B)
Nausea
C)
Muscle tremors
D)
Retractions
E)
Inspiratory stridor
A nurse is discussing pressure ulcer staging with a newly licensed nurse. Which of the following statements should the nurse use to describe a stage 3 pressure ulcer?
A)
A deep crater without visible bone, tendon, or muscle
B)
Unbroken skin with un-blanchable erythema
C)
Full-thickness tissue loss extending to underlying support structures
D)
A shallow, ruptured or intact skin blister without slough
A nurse is reinforcing teaching with a client who has a family history of hypertension. The nurse should inform the client that his blood pressure reading of 128/79 mm Hg places him in which of the following categories?
A)
Elevated blood pressure range
B)
Normal blood pressure range
C)
Hypertension stage 2
D)
Hypertension stage 1
A nurse is collecting data on a client's wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The nurse should recognize this is a manifestation of which of the following?
A)
Infection
B)
Granulation tissue
C)
An inflammatory response
D)
Decreased perfusion

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Exam Review

A nurse is caring for a client who has pneumonia. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?
A)
Initiate humidification therapy.
B)
Raise the head of the bed.
C)
Encourage the client to cough and deep breathe.
D)
Increase the client's oral fluid intake.
A nurse is reinforcing teaching with the parents of a child who is starting to use a spacer with a metered-dose inhaler (MDI) to treat asthma. Which of the following information should the nurse include in the teaching?
A)
Cover exhalation slots of the spacer with lips when inhaling.
B)
The spacer increases the amount of medication delivered to the oropharynx.
C)
The spacer increases the amount of medication delivered to the lungs.
D)
Inhale rapidly when using the spacer with the MDI.
A nurse is reinforcing teaching with a client who has peripheral vascular disease. Which of the following instructions should the nurse include in the teaching?
A)
"Shop for new shoes during the morning hours."
B)
"Wear knee length stockings."
C)
"Incorporate low impact activity into your daily routine."
D)
"Elevate your legs while in bed."
A nurse is reinforcing teaching with a young adult female client who has been prescribed lisinopril. Which of the following instructions should the nurse plan to include? (Select all that apply.)
A)
"Monitor your blood pressure on a regular basis."
B)
"Your cholesterol levels should be monitored monthly while taking this medication."
C)
"Notify your doctor immediately if you become pregnant."
D)
"Report the development of a persistent dry cough."
E)
"Make sure your diet contains a lot of potassium-rich foods."

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Exam Review

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to thin the client's respiratory secretions?
A)
Encourage regular use of the incentive spirometer.
B)
Encourage coughing and deep breathing.
C)
Encourage the client to ambulate more often.
D)
Encourage the client to drink more fluids.
A nurse is reinforcing teaching with a client who is to start taking atorvastatin. The nurse should instruct the client that she will need which of the following baseline examinations prior to starting therapy?
A)
Vision testing
B)
Liver function tests
C)
Dental examination
D)
Papanicolaou test
A nurse is removing a wound dressing that is saturated with blood and purulent drainage. Which of the following methods should the nurse use when disposing of the soiled dressing?
A)
Place the dressing in a biohazardous waste container.
B)
Double bag the dressing, label it "biohazard," and send it for decontamination.
C)
Discard the dressing in the bedside trash receptacle.
D)
Wrap the dressing in a clear plastic bag and discard it in the bedside trash receptacle.
A nurse is caring for a client who has a hearing loss in her left ear. Which of the following nursing actions should the nurse take?
A)
Over articulate words to improve client understanding.
B)
Change voice volume during each sentence.
C)
Minimize background noise to decrease distractions.
D)
Sit in a chair to one side of the client.

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Exam Review

A nurse is collecting data from a client who has peripheral arterial disease (PAD). Which of the following findings should the nurse expect?
A)
Darkened skin color near extremities
B)
Warm extremities
C)
Edema
D)
Intermittent claudication
A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to contribute to the client's plan of care?
A)
Perform passive range of motion daily.
B)
Elevate lower extremities on two pillows.
C)
Auscultate breath sounds at least every two hours.
D)
Make sure the client has an intake of 2.000 ml of fluid per day.
A nurse is collecting data from four clients who have wounds. The nurse should recognize that which of the following clients has a manifestation of a wound infection?
A)
A client who has brown crusting over the wound
B)
A client who has urticaria and itching around the wound
C)
A client who has swelling and tenderness around the wound
D)
A client who has serosanguineous drainage from the wound
A nurse is caring for a client who has moderate anxiety disorder. The client is pacing in the hallway and states, "I am at the end of my rope, I can't take it anymore." Which of the following responses should the nurse make?
A)
"Providers usually recommend relaxation exercises for clients who are as upset as you are."
B)
"Walk with me to an area where we can talk about how you're feeling."
C)
"An antianxiety pill works best for situations like this. Let me get you one."
D)
"Most clients with anxiety issues benefit from lying down."

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Exam Review

A nurse is reinforcing teaching with a client who has hypertension and is taking a beta blocker. Which of the following statements by the client indicates an understanding of the teaching?
A)
"I will not take my medicine if my heart rate is greater than 70/min."
B)
"I should weigh myself on the same day once a week."
C)
"I should expect to develop a slight cough while taking this medication."
D)
"I will sit on the side of the bed before I stand up."
A nurse is caring for a client who has pneumonia and is coughing up secretions. Which of the following actions should the nurse take first?
A)
Encourage the client to increase oral fluids.
B)
Obtain the client's temperature.
C)
Provide chest percussion on the client.
D)
Encourage the client to cough and deep breathe.
A nurse on a medical-surgical unit is assisting with the admission of a client who has vision loss. Which of the following actions is the nurse's priority?
A)
Describe the environment to the client.
B)
Instruct the client to use the call light when preparing to ambulate.
C)
Encourage the client to feel the walls with her hands.
D)
Remove clutter from the client's room.
A nurse is assisting with the care of a school-age child who has respiratory failure due to pneumonia. Which of the following positions should the nurse encourage to allow maximal lung expansion?
A)
Upright
B)
Side-lying
C)
Supine
D)
Prone

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