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)
Loop the tubing of the chest tube on the client's bed.
B)
Strip the client's chest tube every 2 hrs.
C)
Tape the connections on the client's chest tube.
D)
Place the chest tube drainage system above the level of the client's heart.
A nurse is preparing to remove a client's urinary catheter. After performing hand hygiene, which of the following actions should the nurse take?
A)
Deflate the balloon halfway and then pull out the catheter.
B)
Position the client supine.
C)
Have the client bear down during removal.
D)
Cleanse the perineal area with an antiseptic.
A nurse is reinforcing discharge teaching with the parents of an infant who has a prescription for home oxygen and pulse oximetry monitoring. Which of the following statements by the parents indicates a need for further teaching?
A)
"We will rotate the probe of the pulse oximeter every 24 hours."
B)
"The probe of the pulse oximeter can be applied to a finger or a toe."
C)
"The pulse oximeter might not be accurate during times of excessive movement."
D)
"We will notify the doctor if the pulse oximeter consistently reads 100%."
A nurse is caring for a client who has paraplegia and is on an intermittent urinary catheterization program. Which of the following findings indicates to the nurse the need to catheterize the client?
A)
Reflex incontinence
B)
Nocturnal enuresis
C)
Urge incontinence
D)
Suprapubic discomfort

Page 1 of 11

Exam Review

A nurse is assisting with the implementation of a bowel training program for a client. For the program to be effective, the nurse should take the client to the bathroom at which of the following times?
A)
Immediately before meals
B)
Every 2 hr while the patient is awake
C)
When the client has the urge to defecate
D)
After the client feels abdominal cramping
A nurse is caring for a client who has urinary leakage due to nerve damage following a spinal cord injury. The nurse should identify that the client is experiencing which of the following types of urinary incontinence?
A)
Reflex incontinence
B)
Stress incontinence
C)
Urge incontinence
D)
Overflow incontinence
A nurse is reinforcing teaching with a client has reports constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)
(SATA)
A)
Ignoring the urge to defecate
B)
Increased activity
C)
Excessive laxative use
D)
Increased fiber in the diet
E)
Inadequate fluid intake
A nurse is caring for a client who has pneumonia and has been receiving oxygen therapy for several days. When collecting data from the client, the nurse should identify which of the following findings as an indication of an adverse effect of oxygen therapy?
A)
Tachycardia
B)
Excessive pulmonary secretions
C)
Poor skin turgor
D)
Cracks in oral mucous membranes

Page 2 of 11

Exam Review

A nurse is caring for an older adult client. The client has an increased risk for dehydration due to which of the following physiological changes that can occur with aging?
A)
Decrease in systolic blood pressure.
B)
Decrease in kidney function.
C)
Increase in percentage of body water.
D)
Increase in saliva production.
A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan take?
A)
Use one cotton swab to clean the client's urinary meatus.
B)
Don sterile gloves before inserting the indwelling urinary catheter.
C)
Test the balloon on the indwelling urinary catheter before insertion.
D)
Apply an oil-based lubricant to the indwelling urinary catheter.
A nurse is assisting with teaching a client who is preoperative for a sigmoid colostomy. Which of the following statements should the nurse include?
A)
"The end of the stoma will be painful after this procedure."
B)
"You will have a stoma in your left lower abdomen."
C)
"You should expect your stoma to be a purple color."
D)
"Your colostomy produce watery stool.”
A nurse is assisting in the care of a client who has diabetic ketoacidosis and hypoxia. Which of the following actions should the nurse take first?
A)
Obtain a prescription to check the client's glucose level.
B)
Obtain a prescription for supplemental oxygen.
C)
Obtain a prescription to administer intravenous fluids.
D)
Obtain a prescription to administer insulin.

Page 3 of 11

Exam Review

A nurse is collecting data from a client who has a urine output of 250 mL in a 24-hr period. Which of the following terms should the nurse use to document this finding in the electronic record?
A)
Oliguria.
B)
Urgency.
C)
Nocturia.
D)
Dysuria.
A nurse is reinforcing teaching with a client who is at risk for hypokalemia. The nurse should instruct the client that which of the following foods is the best source of potassium?
A)
Spinach
B)
Avocado
C)
Baked potato
D)
Banana
A nurse is assisting with teaching a newly licensed nurse about the function of the large intestine. Which of the following information should the nurse include?
A)
It produces vitamin D.
B)
It absorbs liquid to form stool.
C)
It secretes enzymes to digest food.
D)
It prevents the reflux of food into the esophagus.
A nurse is collecting data on a client who is receiving a unit of PRBCs. Which of the following findings is a manifestation of an allergic transfusion reaction?
A)
Elevated blood pressure
B)
Wheezing
C)
Distended neck veins
D)
Flank pain

Page 4 of 11

Exam Review

A nurse is caring for a client who has a prescription for a stool guaiac test. The client asks the nurse about the purpose of the test. The nurse should respond by stating that the stool guaiac is testing for which of the following findings in the client's feces?
A)
Fat
B)
Blood
C)
Bacteria
D)
Parasites
A nurse is reinforcing teaching with a newly licensed nurse about adverse effects of medications. The nurse should include that which of the following medications can cause constipation?
A)
Iron supplements
B)
Magnesium-containing antacids
C)
Antibiotics
D)
Anticholinergics/antispasmodics
E)
Opioid narcotics
A nurse is collecting data on a client who has respiratory acidosis. Which of the following findings should the nurse expect?
A)
Numbness of fingers
B)
Lethargy
C)
Abdominal pain
D)
Dry skin
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.

Page 5 of 11

Exam Review

A nurse is collecting data on a client who has chronic kidney disease. Which of the following findings is a manifestation of hyperkalemia?
A)
Cerebral edema
B)
Decreased deep tendon reflexes
C)
Hypoactive bowel sounds
D)
Wheezing
A nurse is caring for a client who has nausea and is vomiting. The nurse should identify the client is at risk for which of the following acid-base imbalances?
A)
Respiratory acidosis
B)
Metabolic Acidosis
C)
Metabolic alkalosis
D)
Respiratory alkalosis
A nurse is reinforcing teaching with a newly licensed nurse about obtaining a fecal occult blood test from a client. Which of the following information should the nurse include?
A)
Wait 30 seconds after applying the developing solution to obtain the results.
B)
Apply four drops of developing solution to each stool specimen.
C)
Use toilet paper to transfer the stool specimen.
D)
Collect two stool specimens from the same area of the stool.
A nurse is collecting data on a client who has oxygen toxicity. Which of the following findings should the nurse expect?
A)
Periorbital edema
B)
Facial flushing
C)
Muscle twitching
D)
Metallic taste in mouth

Page 6 of 11