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    Exam Review

    1. A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?
      A)
      The client is unable to move any extremity
      B)
      The client is unable to make vocal sound
      C)
      The client opens his eyes when spoken to
      D)
      The client is unconscious
    2. A nurse is assessing a client who has meningitis and notices the client grimace in pain when extending the leg from a flexed position. Which of the following conditions is the client displaying?
      A)
      Kernig’s sign
      B)
      Brudzinski’s sign
      C)
      Nuchal rigidity
      D)
      Bradykinesia
    3. A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?
      A)
      Provide fluid hydration
      B)
      Reduce edema of the brain
      C)
      Increase cell size in the brain
      D)
      Expand extracellular fluid volume
    4. A client in the intensive care unit is experiencing an ST-elevation myocardial infarction (STEMI) confirmed by the 12-lead EKG. Which of the following interventions will the nurse anticipate for this client?
      A)
      Discontinue intravenous access
      B)
      Prepare client for a non-contrast CT scan
      C)
      Hold anticoagulant therapies
      D)
      Prepare client for a cardiac catheterization
    Page 1 of 10

    Exam Review

    1. A nurse is instructing a client’s family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?
      A)
      Place the client with the head reclined back to facilitate swallowing
      B)
      Encourage brief exercise before meals to promote appetite
      C)
      Encourage the client to take small bites
      D)
      Place food in the affected side of the mouth
    2. A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?
      A)
      Administer a nitrate antihypertensive
      B)
      Obtain the client’s heart rate
      C)
      Place the client in a high-Fowler’s position
      D)
      Check for bladder distention
    3. A nurse is caring for a client who just had a cardiac catheterization through the left femoral vessel. Which of the following nursing interventions should the nurse include in the client’s plan of care? (Select all that apply)
      (SATA)
      A)
      Measure vital signs every 6 hr
      B)
      Sit the client upright immediately after the procedure
      C)
      Keep the client’s hip and leg extended straight
      D)
      Check all pulses on the left lower extremity
      E)
      Have the client remain in bedrest up to 6 hrs as prescribed
    4. A nurse is monitoring a client who has hydrocephalus. Which of the following manifestations should indicate to the nurse the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply)
      (SATA)
      A)
      Disorientation
      B)
      Anuria
      C)
      Neck pain and stiffness
      D)
      Pupillary changes
      E)
      Headache
    Page 2 of 10

    Exam Review

    1. A nurse is teaching a family member of a client who had an acute myocardial infarction (MI) about the reason for the frequent blood draws from the client. Which of the following statements is appropriate for the nurse to say when educating the family member about cardiac enzymes?
      A)
      Cardiac enzymes assist in diagnosing the presence of pulmonary congestion
      B)
      These tests will enable the provider to determine the heart structure and mobility of the heart valves
      C)
      These tests help determine the degree of damage to the heart tissues
      D)
      Cardiac enzymes will identify the location of the MI
    2. A nurse caring for a client who has developed homonymous hemianopia affecting their left visual field after a stroke. Which of the following interventions is appropriate for this client?
      A)
      Have the client wear sunglasses
      B)
      Encourage the client to scan the room from left to right
      C)
      Apply ointment to the client’s eyes
      D)
      Teach client to scan the room from right to left
    3. A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse’s priority?
      A)
      The client’s ECG tracing shows irregular heart rate without P waves
      B)
      The client’s urine output is cloudy and odorous
      C)
      The client develops slurred speech
      D)
      The client has an aPTT of 80 seconds
    4. A newly licensed nurse is assessing a client who had a cardiac catheterization with a right femoral insertion site. Which of the following pulses should the nurse palpate?
      A)
      Brachial pulse in the right upper extremity
      B)
      Pedal pulses in the right lower extremity
      C)
      Popliteal pulse in the left lower extremity
      D)
      Radial pulse in the right upper extremity
    Page 3 of 10

    Exam Review

    1. A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, and shoulder with shortness of breath and nausea. Which of the following actions should the nurse take?
      A)
      Obtain a 12-lead EKG
      B)
      Administer enteric-coated acetaminophen
      C)
      Obtain an echocardiogram
      D)
      Administer ibuprofen
    2. A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm?
      A)
      The P wave appears before the QRS complex
      B)
      The QRS duration is 0.35 seconds
      C)
      The P wave appears after the QRS complex
      D)
      The P-R interval measures 0.40 seconds
    3. A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following orders should the nurse clarify with the provider?
      A)
      Serum cardiac enzyme levels
      B)
      MRI of the heart and great vessels
      C)
      Low-sodium diet
      D)
      Low impact physical therapy
    4. A nurse is planning care for a client who had a traumatic brain injury and is waking up restlessly from a coma. Which of the following interventions should the nurse include in the plan?
      A)
      Administer opioids
      B)
      Reduce stimuli
      C)
      Apply restraints
      D)
      Administer antihypertensives
    Page 4 of 10

    Exam Review

    1. A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?
      A)
      Suction saliva from the client’s mouth
      B)
      Perform passive range of motion on each extremity
      C)
      Monitor the client’s electrolyte levels
      D)
      Record the client’s intake and output
    2. A nurse in the emergency department is caring for a client who presents with non-ST elevation myocardial infarction (NSTEMI). Which of the following actions should the nurse take first?
      A)
      Attach the leads for continuous cardiac monitoring
      B)
      Initiate oxygen therapy
      C)
      Insert the IV catheter
      D)
      Obtain a blood sample
    3. A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse take first?
      A)
      Evaluate the client’s neurological status
      B)
      Perform a complete blood count
      C)
      Administer an oral analgesic
      D)
      Check the client’s temperature
    4. A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take?
      A)
      Teach controlled coughing and deep breathing
      B)
      Elevate the head of the bed
      C)
      Encourage a minimum intake of 4,000 mL of clear fluids per day
      D)
      Provide a brightly lit environment
    Page 5 of 10

    Exam Review

    1. A nurse enters a client’s room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?
      A)
      Gently restrain the client’s extremities
      B)
      Place the client on a BiPAP machine for oxygenation
      C)
      Place a pillow under the client’s head
      D)
      Insert a padded tongue blade into the client’s mouth
    2. A nurse is admitting a young adult client who has suspected bacterial meningitis. The nurse should closely monitor the client for increased intracranial pressure (ICP) as indicated by which of the following findings?
      A)
      Nuchal rigidity
      B)
      Widened pulse pressure
      C)
      Elevated temperature
      D)
      Pupils reactive to light
    3. A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider?
      A)
      Edematous bruise on forehead
      B)
      Glasgow Coma Scale (GCS) score of 14
      C)
      Pupils are 4 mm and reactive to light
      D)
      Small drops of clear drainage in the client’s ear
    4. A nurse is caring for a newly admitted client with an aortic dissection. The nurse proceeds to implement new orders, which of the following is appropriate for this client?
      A)
      Opioid therapy
      B)
      Promote a quiet environment by clustering care
      C)
      Encourage heavy weight lifting for physical activity
    Page 6 of 10