Exam Review

A nurse is caring for a client who is receiving warfarin (Coumadin) therapy to prevent a deep vein thrombosis. Which of the following medications should the nurse have available in the event of an overdose?
A)
Epinephrine.
B)
Protamine.
C)
Atropine.
D)
Vitamin K
A nurse is caring for a female client who is scheduled to have a pelvic examination. The client tells the nurse, "I'm really nervous because I've never had a pelvic exam before.”. Which of the following is an appropriate therapeutic response by the nurse?
A)
"A pelvic exam is required if you want birth control pills.”.
B)
"Don't worry, I will stay in there with you for the exam.”.
C)
"Tell me more about your concerns.”.
D)
"All you need to do is relax during the exam.”.
A nurse is caring for a client who has a prescription for 81 mg acetylsalicylic acid (Aspirin) daily. Which of the following actions should the nurse plan to take?
A)
Monitor the client for a pain rating of 6 or more.
B)
Encourage the client to eat more green leafy vegetables.
C)
Monitor the client for black, tarry stools.
D)
Monitor the client for a sudden drop to their blood urea nitrogen (BUN) and creatinine levels.
A nurse is preparing to administer enoxaparin sodium (Lovenox) subcutaneously to a client. Which of the following is an appropriate action by the nurse?
A)
Inject the medication into the abdomen at least 2 inches from the umbilicus.
B)
Massage the injection site after administration of the medication.
C)
Use a 1-inch needle to inject the medication.
D)
Use a 22-gauge needle to inject the medication.

Page 1 of 10

Exam Review

A nurse is reinforcing teaching with an older adult client who has osteoporosis. Which of the following recommendations should the nurse include?
A)
Decrease intake of Vitamin D.
B)
Walk five times a week.
C)
Use corticosteroids to decrease pain.
D)
Apply cool clothes to sore joints.
A nurse is caring for a client who has a deep vein thrombosis, who received IV anticoagulation therapy for the past 5 days, and now has a new prescription for oral warfarin (Coumadin) in addition to subcutaneous enoxaparin sodium (Lovenox) injections. The client asks the nurse if both medications are necessary. Which of the following is an appropriate response by the nurse?
A)
"Both enoxaparin sodium and warfarin work together to dissolve the clots.”.
B)
"Enoxaparin sodium injections will be discontinued once warfarin reaches a therapeutic level.”.
C)
"Enoxaparin sodium enhances the effects of the warfarin.”.
D)
"I will ask the charge nurse to call your provider and get an explanation.”.
A student nurse is helping with the care of a client receiving an IV heparin infusion. Which medication should be readily available in case of a heparin overdose?
A)
Protamine sulfate.
B)
Vitamin K.
C)
Glucagon.
D)
Ferrous sulfate.
A nurse is assessing an older adult client who has a urinary tract infection (UTI). Which of the following findings should the nurse identify as unique for this age group?
A)
Low back pain.
B)
Incontinence.
C)
Confusion.
D)
Urinary retention.

Page 2 of 10

Exam Review

A nurse is caring for a client who is postoperative following a colon resection. For which of the following findings should the nurse monitor to identify a pulmonary embolus?
A)
Swelling of lower extremity.
B)
Burning sensation when voiding.
C)
Sudden shortness of breath.
D)
Purulent drainage at suture line.
A nurse is assuming care of a client who has an existing deep-vein thrombosis (DVT). What interventions would be anticipated in their plan of care? (Select All that Apply).
(SATA)
A)
Encourage and assist with turning every 2 hours.
B)
Position the legs dependently.
C)
Administer ibuprofen for pain relief.
D)
Monitor platelet levels.
E)
Apply ice to the extremity.
F)
Evaluate fit of compression stockings.
The clinic nurse is obtaining information from a client who presents for her annual wellness exam. Which of the following statements should be used when taking a sexual health history?
A)
"Do you practice safe sex, or should we discuss ways to improve your habits?".
B)
"We don't need to discuss sexual health unless you have specific concerns.”.
C)
"You're not sexually active, right? That will make this part of the visit quick.”.
D)
"Tell me about your sexual partners and practices to ensure I address your sexual health needs.”.
A nurse is caring for a toddler who had a cast applied 2 hours ago due to multiple fractures of the right hand. Which of the following findings should the nurse report immediately to the charge nurse?
A)
The parent reports the child will not keep the arm elevated on the pillow.
B)
The fingers on the right hand have a capillary refill of 4 seconds.
C)
The fingertips of the right hand are swollen and bruised.
D)
The child is not attempting to move her right arm or fingers.

Page 3 of 10

Exam Review

A nurse is caring for a client who has thrombophlebitis and is receiving a continuous infusion of heparin. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse make?
A)
"The time it takes heparin to dissolve clots varies between clients.”.
B)
"It usually takes at least 2 to 3 days for heparin to dissolve a clot.”.
C)
"The time it takes for heparin to dissolve a clot depends on the size of the clot.”.
D)
"Heparin prevents new clots from forming rather than dissolving established clots.”.
A nurse is contributing to the plan of care for a client to achieve the outcome of functional healing of a fracture. Which of the following nursing interventions is the highest priority to assist in meeting this outcome?
A)
Provide optimal nutrition and hydration for the client.
B)
Maintain immobilization and alignment for the client.
C)
Provide relief from pain and discomfort for the client.
D)
Promote independence in activities of daily living for the client.
A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions is the priority for the nurse to take?
A)
Maintain an IV infusion of lactated Ringer's.
B)
Administer IV morphine.
C)
Initiate cardiac monitoring.
D)
Begin oxygen therapy.
A nurse is caring for an older adult client who has confusion and weakness. The client has an elevated hematocrit (Hct) of 53%, an elevated blood urea nitrogen (BUN) of 25 mg/dL, and an elevated urine specific gravity of 1.032.Which of the following actions should the nurse contribute to the client's plan of care? (Select all that apply).
A)
Monitor the client's intake and output.
B)
Check the client's orientation to person, place, and time regularly.
C)
Restrict the client's fluid intake.
D)
Instruct the client to sit on the side of the bed for a few minutes before standing.
E)
Weigh the client daily.

Page 4 of 10

Exam Review

A nurse is planning a low-protein diet for a client who has chronic renal failure. The client states, "Why do I have to be concerned with protein?". Which of the following responses is appropriate?
A)
A low-protein diet will help your body retain more fluid.
B)
Protein breakdown produces waste products that can build up in your body.
C)
Protein impairs the body's ability to store potassium.
D)
High protein intake can cause calcium retention.
A nurse is caring for a client who has Chlamydia and a new prescription for an antibiotic. Which of the following statements should the nurse include when reinforcing teaching regarding this disease and treatment?
A)
It is very likely that you will have difficulty getting pregnant in the future.
B)
You may resume sexual activity once your symptoms improve.
C)
The Chlamydia bacteria will go dormant with treatment but it may return.
D)
Your sexual partner(s) should receive testing and treatment.
A nurse is collecting data from a client who has a urinary tract infection.Which of the following findings should the nurse expect? (Select all that apply.)
A)
Polyuria.
B)
Urinary frequency.
C)
Dysuria.
D)
Dependent edema.
E)
Hematuria.
A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there has not been any urinary output in the last hour. Which of the following actions should the nurse perform first?
A)
Offer oral fluids.
B)
Notify the provider.
C)
Administer a prescribed analgesic.
D)
Determine the patency of the tubing.

Page 5 of 10

Exam Review

A nurse is providing safe sex education to a group of adolescents.Which of the following statements should the nurse include in the education? (Select all that apply.)
A)
Having multiple sexual partners increases the risk of sexually transmitted infection (STI) transmission.
B)
Using condoms consistently and correctly can help prevent the transmission of STIs.
C)
Engaging in oral sex does not pose any risk of STI transmission.
D)
Getting vaccinated against HPV reduces the risk of many sexually transmitted infections.
E)
Birth control pills provide protection against STIs.
F)
Abstinence is the only foolproof method to prevent STIs and unintended pregnancies.
A nurse is completing a home care visit for a 75-year-old client who began enoxaparin sodium (Lovenox) therapy 2 weeks ago. The nurse is providing teaching regarding managing a bleeding episode in the event of an accidental injury with the client and his spouse. Which of the following statements by the spouse indicates a need for further teaching?
A)
I will apply a bandage wrap to the site.
B)
I will monitor the site for re-bleeding.
C)
I will elevate the affected area if possible.
D)
I will remind my spouse to rest in order to minimize the risk of re-bleeding.
A nurse is caring for a client who is postoperative following a total knee replacement. Which of the following actions should the nurse implement to prevent deep vein thrombophlebitis?
A)
Closely monitor the White Blood Cell (WBC) count.
B)
Encourage increased fluid intake.
C)
Keep the affected knee flexed.
D)
Promote bed rest for 5 days.
A nurse is reinforcing teaching with a client following surgery who has antiembolism stockings in place. Which of the following information should the nurse include in the teaching?
A)
The stockings replace the need for postoperative leg exercises.
B)
The stockings are used to reduce pain.
C)
The stockings prevent varicose veins.
D)
The stockings prevent venous stasis.

Page 6 of 10