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    Exam Review

    1. A nurse is caring for a client. Exhibits Which of the following actions should the nurse take? Select all that apply.
      (SATA)
      A)
      Wear an N95 mask when caring for the client.
      B)
      Place the client in a private room.
      C)
      Place the client on droplet isolation precautions.
      D)
      Assign client to a negative air pressure room.
      E)
      Ensure the client wears a mask when outside their room.
    2. A nurse on a medical-surgical unit is reviewing the electronic health record of a client who is being admitted from the emergency department. Exhibits After reviewing the client's EHR, which of the following client's findings require further follow-up by the nurse?
      (Highlight — findings requiring follow-up are marked)

      A nurse on a medical-surgical unit is reviewing the electronic health record of a client who is being admitted from the emergency department.

      Exhibits

      After reviewing the client's EHR, which of the following client's findings require further follow-up by the nurse?

      Click to highlight the client's findings that require further follow-up by the nurse. To deselect a finding, click on the finding again.

      Body System

      Findings

      Gastrointestinal

      Client reports abdominal pain as a 9 on a pain scale of 0 to 10.

      Abdomen is distended and firm.

      Bowels sounds are distant and hypoactive.

      Integumentary

      Skin is warm and dry.

      Perianal skin is excoriated, and small ulceration is noted.

      Fluid balance

      Tenting of skin for 4 seconds is noted.

      Capillary refill is 2 seconds.

      Temperature 38.7° C (101.7° F)

      Mucous membranes are dry.

      Respiratory rate 20/min
    3. The following two graphic loops show which of the following conditions?
      A ✓ Correct
      Option A
      A)
      COPD
      B)
      Atelectasis
      C)
      Pneumothorax
      D)
      Pulmonary oedema
    4. A nurse is creating a plan care for a client who requires suture removal. Which of the following actions should the nurse plan to take?
      A)
      Pull the visible part of the suture through the underlying tissue.
      B)
      Cleanse the wound with sterile water prior to removing the sutures.
      C)
      Cut the sutures as close to the skin as possible.
      D)
      Remove the sutures in a consecutive order.
    Page 1 of 15

    Exam Review

    1. A nurse manager is teaching a group of newly licensed nurses about which procedures are within their scope of practice. Which of the following examples should the nurse include in the teaching?
      A)
      Insertion of an endotracheal tube
      B)
      Monitoring a continuous intra-arterial infusion of a thrombolytic medication
      C)
      Placement of nylon sutures
      D)
      Administering a bolus dose of medication through an epidural catheter
    2. A nurse is caring for a client who had a stroke and is immobile. Which of the following actions should the nurse take to maintain the client's skin integrity?
      A)
      Insert an indwelling urinary catheter.
      B)
      Use an alcohol-free barrier product.
      C)
      Reposition the client every 4 hr.
      D)
      Massage the skin over bony prominences.
    3. A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?
      A)
      Request additional information about the caller's relationship to the client.
      B)
      Provide a general update about the client's condition over the telephone.
      C)
      Refer the family member to the client's provider for the update.
      D)
      Encourage the family member to contact the client directly for information.
    4. A nurse is planning an in-service about foot care for a group of clients who have peripheral neuropathy. Which of the following information should the nurse include?
      A)
      Apply foot cream between the toes.
      B)
      Use a pumice stone to soften calluses.
      C)
      Inspect the feet daily using a mirror.
      D)
      Round the toenail edges when clipping.
    Page 2 of 15

    Exam Review

    1. A nurse is performing a family assessment for a client who has recently developed paraplegia following a stroke. Which of the following actions should the nurse take first?
      A)
      Determine how the client views the concept of a family.
      B)
      Identify how culture influences family functioning.
      C)
      Determine if the client has an external support system.
      D)
      Identify how the family deals with unexpected health changes.
    2. A nurse is teaching a client to manage stress by using progressive relaxation techniques. Which of the following statements by the client indicates an understanding of the teaching?
      A)
      "I should breathe normally while I am performing this relaxation technique."
      B)
      "I should imagine myself in a peaceful, garden-like setting as I begin."
      C)
      "I'll compare the sensations I feel when I tense my muscles to what I feel when I relax them."
      D)
      "I'll use a series of stretches when I practice this technique."
    3. A nurse is caring for a client who is disoriented and is continuously getting out of bed. Which of the following actions should the nurse take? (Select all that apply.)
      A)
      Only use restraints if the client becomes violent.
      B)
      Use seclusion to manage the client's behavior.
      C)
      Attempt the use of less restrictive methods before using restraints.
      D)
      Use restraints for the minimum amount of time necessary.
      E)
      Ensure the restraint limits the client's movement as little as possible.
    4. A nurse is planning care for a client who is receiving an IV fluid infusion. Which of the following interventions should the nurse implement to maintain asepsis?
      A)
      Change the secondary IV infusion set twice weekly.
      B)
      Change a continuously infusing IV bag after 48 hr.
      C)
      Change the primary IV infusion set every 96 hr.
      D)
      Change the extension tubing once per week.
    Page 3 of 15

    Exam Review

    1. A nurse has administered 5 mL of medication to a client via NG tube. They used 30 mL of water to flush the tube both before and after the instillation. The nurse should document which of the following amounts as liquid intake for the client?
      A)
      65 mL
      B)
      5 mL
      C)
      35 mL
      D)
      60 mL
    2. A nurse is preparing to notify the provider about a change in a client's status. Which of the following information should the nurse plan to include in the "background" portion of the Situation, Background, Assessment, Recommendation (SBAR) communication tool?
      A)
      Client's present condition
      B)
      Questions for the provider regarding client care
      C)
      Physical findings
      D)
      Previous treatments
    3. A nurse is planning teaching for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following actions should the nurse take prior to performing the teaching? (Select all that apply.)
      A)
      Establish the client's learning needs.
      B)
      Determine the client's literacy level.
      C)
      Evaluate the client's readiness for learning.
      D)
      Verify the client's computer access.
      E)
      Identify the client's learning style.
    4. A nurse is preparing to administer an opioid medication to a client who is experiencing pain. Which of the following actions should the nurse take?
      A)
      Dispose of the wasted portion of the opioid medication in the sharps box.
      B)
      Count the total amount of opioid medication remaining after removing the needed amount.
      C)
      Ask a second nurse to witness the discarding of unused opioid medication.
      D)
      Report opioid medication count discrepancies to the provider.
    Page 4 of 15

    Exam Review

    1. A nurse is performing postmortem care for a client who has just died. Which of the following actions should the nurse take?
      A)
      Close the client's eyes with paper tape.
      B)
      Identify the client using two identifiers.
      C)
      Remove the client's pillow to prevent discoloration of the face.
      D)
      Remove the client's dentures.
    2. A nurse is assessing a client who has hypokalemia. Which of the following findings should the nurse expect?
      A)
      Strong, bounding pulse
      B)
      Positive Chvostek's sign
      C)
      Hyperactive reflexes
      D)
      Decreased bowel sounds
    3. A nurse is assessing a client for hearing acuity by performing the Rinne test. Which of the following actions should the nurse take?
      A)
      Place a vibrating tuning fork on the top of the client's head.
      B)
      Move a vibrating tuning fork's prongs in front of the client's left or right ear canal.
      C)
      Activate a tuning fork and place the prongs on the client's occipital area.
      D)
      Instruct the client to occlude one ear and repeat a softly spoken phrase by the nurse.
    4. A home health nurse is teaching a client who has a latex allergy about items typically found in the home that can trigger an allergic reaction. Which of the following items should the nurse instruct the client to avoid? (Select all that apply.)
      A)
      Dishwashing gloves
      B)
      Adhesive tape
      C)
      Macadamia nuts
      D)
      Bananas
      E)
      Rubber bands
    Page 5 of 15

    Exam Review

    1. A nurse is assessing a client who has an NG tube and is receiving continuous enteral feedings. The nurse auscultates coarse crackles in the client's lungs. After discontinuing the feeding, which of the following actions should the nurse take next?
      A)
      Prepare to initiate antibiotic therapy.
      B)
      Obtain a prescription for a chest x-ray.
      C)
      Position the client on their side.
      D)
      Suction the client's orotracheal airway.
    2. A nurse is caring for a client who reports having insomnia due to increased stress. Which of the following actions should the nurse take first?
      A)
      Determine the source of the client's stress.
      B)
      Instruct the client to turn off their TV just before they go to bed.
      C)
      Encourage the client to listen to soft music at the onset of stress.
      D)
      Advise the client to exercise daily in the morning.
    3. A nurse is receiving a change-of-shift report for a group of clients. Which of the following clients should the nurse plan to see first?
      A)
      A client who needs their daily weight taken with a bed scale
      B)
      A client who has a leg ulcer and needs their dressing changed
      C)
      A client who has an indwelling urinary catheter bag that needs to be emptied
      D)
      A client who has dysphagia and has a scheduled feeding
    4. A nurse is caring for a client who has terminal cancer. The client begins to cry and says, "I am afraid of dying." Which of the following responses should the nurse make?
      A)
      "I think you should call your friends to comfort you."
      B)
      "Things are not as bad as they seem right now."
      C)
      "It must be a very difficult time for you."
      D)
      "Why are you afraid that you are going to die?"
    Page 6 of 15