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    Exam Review

    1. A nurse enters a client's room to administer medication and finds the client lying in bed disoriented with labored and fast respirations. Which of the following actions should the nurse take first?
      A)
      Prepare the client for endotracheal suctioning.
      B)
      Obtain a sputum culture.
      C)
      Request a chest x-ray.
      D)
      Elevate the head of the bed.
    2. 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)
      Suprapubic discomfort/bladder distention
      B)
      Nocturnal enuresis
      C)
      Urge incontinence
      D)
      Reflex incontinence
    3. Which of the following conditions is characterized by an excessive forward curvature of the upper spine?
      A)
      Kyphosis
      B)
      Osteoporosis
      C)
      Scoliosis
      D)
      Lordosis
    4. A nurse is reinforcing teaching with a newly licensed nurse about the manifestations of hypoxia. Which of the following findings should the nurse include in the teaching?
      A)
      Dysphagia
      B)
      Cyanosis
      C)
      Nausea
      D)
      Warm, dry skin
    Page 1 of 9

    Exam Review

    1. A nurse is collecting data from a client who has contact dermatitis of the neck and upper chest. Which of the following findings should the nurse expect?
      A)
      Reports of exposure to a skin irritant
      B)
      Denial of pruritus
      C)
      Elevated temperature
      D)
      Reports of joint discomfort
    2. A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse take to prevent the development of skin breakdown?
      A)
      Request a prescription for the insertion of an indwelling urinary catheter.
      B)
      Clean the skin and perineum with hot water after each episode of incontinence.
      C)
      Check the client's skin every 8 hr for signs of breakdown.
      D)
      Apply a moisture barrier ointment to the skin.
    3. Which of the following factors can affect normal urination? (Select All that Apply.)
      (SATA)
      A)
      Dehydration
      B)
      Certain medications
      C)
      Consuming caffeine
      D)
      Maintaining a balanced diet
      E)
      Regular exercise
      F)
      Urinary tract infection
    4. A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the client's skin integrity?
      A)
      Provide the client with a diet high in protein.
      B)
      Apply cornstarch to keep the skin dry.
      C)
      Massage bony prominences to promote circulation.
      D)
      Reposition the client every 3 hr.
    Page 2 of 9

    Exam Review

    1. Which assessment finding is consistent with a client with scoliosis?
      A)
      Joint stiffness and swelling
      B)
      Abdominal pain and bloating
      C)
      Uneven shoulders and waistline
      D)
      Chest pain and shortness of breath
    2. A nurse is assisting a client with range-of-motion exercises of the feet and ankles. Which of the following terms should the nurse use when documenting the client extending her leg and bending her foot and toes downward toward the floor?
      A)
      Inversion
      B)
      Plantar flexion
      C)
      Eversion
      D)
      Dorsiflexion
    3. A nurse is collecting data on a client for manifestations of pain. Which of the following findings is a subjective indicator of pain?
      A)
      The client is restless.
      B)
      The client's pupils are dilated.
      C)
      The client reports a burning sensation.
      D)
      The client is grimacing.
    4. A nurse is collecting data from a client who reports finding a new skin lesion. Which of the following actions is the nurse's priority?
      A)
      Document the client's history of skin allergies.
      B)
      Instructing the client on the use of daily sunscreen products.
      C)
      Photograph the lesion for the client's medical record.
      D)
      Identify when the client first noticed the lesion.
    Page 3 of 9

    Exam Review

    1. A nurse assisting in the care of a client who has a mood disorder. Which of the following client statements by the client indicates readiness for discharge?
      A)
      "I will take my medicines as I should and know who to call if I have bad thoughts."
      B)
      "Right now, I can't bathe or dress myself, but my family will help me."
      C)
      "I can always come stay in the hospital again if I don't want to take care of my own needs."
      D)
      "Taking care of myself is important, but it's okay if I don't want to do anything."
    2. A nurse is reinforcing teaching with a client about the risk factors for skin cancer. Which of the following statements by the client indicates an understanding of the teaching?
      A)
      "My father was treated for melanoma, but skin cancer isn't related to genetics."
      B)
      "I need to use sunscreen even in winter."
      C)
      "I used to lie in the sun all the time, but now I just go to the tanning bed."
      D)
      "Because I have a light complexion, I have a decreased risk for skin cancer."
    3. 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.)
      A)
      (Select All that Apply.)
      B)
      Ignoring the urge to defecate
      C)
      Excessive laxative use
      D)
      Increased activity
      E)
      Inadequate fluid intake
      F)
      Increased fiber in the diet
    4. A nurse is caring for a client who is pregnant and reports constipation. Which of the following recommendations should the nurse make?
      A)
      Maintenance of good posture
      B)
      Regular use of glycerine suppositories
      C)
      Regular use of a laxative
      D)
      Increased fiber and fluid in the diet
      E)
      Inadequate fluid intake
    Page 4 of 9

    Exam Review

    1. An older adult client in a long-term care facility has dementia and begins to have frequent episodes of urinary incontinence. After the provider finds no medical cause for his incontinence, which of the following interventions should the nurse initiate to manage this behavior?
      A)
      Take the client to the bathroom on an every-2-hr schedule.
      B)
      Remind the client to tell the nurse when he has to urinate.
      C)
      Use adult diapers to prevent frequent clothing changes.
      D)
      Request a prescription for an indwelling urinary catheter.
    2. A nurse is collecting data about a client's skin turgor. Which of the following actions should the nurse take?
      A)
      Observe for nonblanching, pinpoint-size, red or purple spots on the skin of the abdomen.
      B)
      Press the skin over the client's ankle bone.
      C)
      Grasp a fold of skin under the client's clavicle or near the sternum.
      D)
      Lightly palpate the skin using the fingertips.
    3. A client with a chronic wound is receiving wound care. Which of the following nutrients is most important for promoting skin integrity and wound healing?
      A)
      Vitamin B12
      B)
      Protein
      C)
      Zinc
      D)
      Vitamin K
    4. A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?
      A)
      Prior to palpating the abdomen
      B)
      After checking for kidney tenderness
      C)
      Prior to inspecting the abdomen
      D)
      After palpating the abdomen
    Page 5 of 9

    Exam Review

    1. Which of the following statements accurately connects skin integrity and infection? (Select All that Apply.)
      A)
      A compromised skin barrier increases the risk of infection.
      B)
      Infection only affects the superficial layers of the skin.
      C)
      Healthy skin is resistant to infection.
      D)
      Skin infections have no impact on skin integrity.
      E)
      The risk of infection is not influenced by the presence of moisture on the skin.
      F)
      Infection slows the healing process of wounds.
    2. What is an effective strategy for fostering independence in a client with mobility issues?
      A)
      Perform all tasks for the client to ensure their safety.
      B)
      Discourage the client from attempting any activities that may be challenging.
      C)
      Encourage the client to rely on others for all activities of daily living.
      D)
      Assist the client in developing skills to perform activities of daily living on their own.
    3. A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?
      A)
      Ask the client if she has been out of bed today.
      B)
      Ask the client how strong she feels today.
      C)
      Ask the client to push her legs and feet against the nurse's palms.
      D)
      Check the client's pedal pulses and feet for edema.
    4. A nurse in an acute mental health center is performing a physical assessment on a client. Which of the following findings should the nurse document under the integumentary system? (Select all that apply.)
      A)
      Jaundice
      B)
      Numbness
      C)
      Needle tracks
      D)
      Skeletal deformities
      E)
      Ecchymosis
    Page 6 of 9