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    Exam Review

    1. A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?
      A)
      Mix the three medications together prior to administering.
      B)
      Flush the NG feeding tube with 30 mL of water immediately following medication administration.
      C)
      Dilute each medication with 10 mL of tap water.
      D)
      Maintain the head of the bed in a flat position for 30 min following medication administration.
    2. A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following?
      A)
      Urinary retention
      B)
      Urinary tract infection
      C)
      Urinary incontinence
      D)
      Urinary frequency
    3. A nurse is providing teaching about a heart-healthy diet to a group of clients with hypertension. Which of the following statements by one of the clients indicates a need for further teaching?
      A)
      "I may thicken gravies with cornstarch as I cook."
      B)
      "Fresh fruits make a good snack option."
      C)
      "I may eat 2 cans of soup a day."
      D)
      "I will replace table salt with dried herbs."
    4. A nurse is caring for a client who needs to increase his protein intake. The client tells the nurse some of the food he enjoys. Which of the following foods should the nurse recommend as the best source of protein among these suggestions?
      A)
      Peanuts
      B)
      Chicken
      C)
      Yams
      D)
      Eggs
    Page 1 of 12

    Exam Review

    1. A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure?
      A)
      Nurse
      B)
      Surgical suite nurse
      C)
      Anesthesiologist
      D)
      Surgeon
    2. A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. Which of the following actions should the nurse take?
      A)
      Observe the client before taking further action.
      B)
      Perform the Heimlich maneuver
      C)
      Slap the client on the back several times.
      D)
      Assist the client to the floor and begin mouth-to-mouth resuscitation.
    3. A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take?
      A)
      Discard the tablet and obtain another dose of medication.
      B)
      Use the tablet's packaging to pick it up from the counter.
      C)
      Wash the tablet off with alcohol and place it in a clean medication cup.
      D)
      Place the tablet directly into a medication cup.
    4. A nurse is preparing to administer oral medications to a client. Which of the following should the nurse recognize as an acceptable client identifier? (Select All that Apply)
      (SATA)
      A)
      Provider's name
      B)
      Facility-assigned identification number
      C)
      Facility room number
      D)
      Partner's full name
      E)
      Client's full name
    Page 2 of 12

    Exam Review

    1. A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client's infection?
      A)
      Encouraging the client to consume a high-protein diet
      B)
      Performing hand hygiene before, during, and after direct contact with the client
      C)
      Placing the client in a room with positive-pressure airflow
      D)
      Changing the client's bed linens each day
    2. A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?
      A)
      Finger
      B)
      Skin fold
      C)
      Toe
      D)
      Earlobe
    3. A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. Which of the following actions should the nurse take?
      A)
      Use attentive listening with the client.
      B)
      Focus on the client's present circumstances instead of his personal stories.
      C)
      Offer the client personal thoughts and beliefs.
      D)
      Verbalize understanding of how the client feels.
    4. A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include in the client's plan of care?
      A)
      Perform range-of-motion (ROM) exercises at least two to three times daily.
      B)
      Auscultate breath sounds at least every 2 hr.
      C)
      Make sure the client has an intake of 2,000 to 3,000 mL of fluid per day.
      D)
      Apply anti-embolic stockings.
    Page 3 of 12

    Exam Review

    1. A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first?
      A)
      Complete an incident report.
      B)
      Notify the nurse manager.
      C)
      Call the client's provider.
      D)
      Assess the client.
    2. A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which of the following is most important for the nurse to determine?
      A)
      The client's height
      B)
      The client's ability to communicate
      C)
      The client's current weight-bearing status
      D)
      The type of equipment used in previous transfers
    3. A nurse is reinforcing teaching with a client about using transdermal patches at home. Which of the following statements should the nurse identify as an indication that the client understands the teaching?
      A)
      “I will clean and dry the area before applying the patch."
      B)
      “I will use lotion on irritated skin before applying a new patch in that area."
      C)
      “I will remove the old patch and apply a new one in the same location."
      D)
      “I will press the patch securely in place on my forearm."
    4. A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements should the nurse identify as an indication that the client needs further teaching?
      A)
      "I'll need to shave the hair off the skin where I place the electrodes."
      B)
      "I hope I don't have to take as many pain pills."
      C)
      "I wish I didn't have to attach the electrodes to my skin."
      D)
      "It's unfortunate that I have to be in the hospital for this treatment."
    Page 4 of 12

    Exam Review

    1. A charge nurse is planning a room assignment for a client who has a productive cough, a questionable chest x-ray, and a positive Mantoux test. Which of the following rooms should the nurse assign to the client?
      A)
      A private, negative-pressure room
      B)
      A private, positive-pressure room
      C)
      A semi-private, negative-pressure room
      D)
      A semi-private, positive-pressure room
    2. A nurse is caring for a client who is scheduled for an elective surgical procedure. Which of the following actions should the nurse take regarding informed consent?
      A)
      Obtain the client's consent.
      B)
      Explain the procedure to the client if they do not understand.
      C)
      Witness the client's signature.
      D)
      Explain the risks and benefits of the procedure.
    3. A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?
      A)
      Apply petroleum jelly to the client's lips after oral care.
      B)
      Use a stiff toothbrush to clean the client's teeth.
      C)
      Use the thumb and index finger to keep the client's mouth open.
      D)
      Turn the client on his side before starting oral care.
    4. A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? (Select All that Apply.)
      A)
      Assess the client every 4 hours.
      B)
      Place a fall-risk identification band on the client's wrist.
      C)
      Keep the client's room dark at night.
      D)
      Teach the client to use the call light.
      E)
      Keep the client's bed in the lowest position.
    Page 5 of 12

    Exam Review

    1. A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal?
      A)
      Urinary frequency for several days
      B)
      Temporary urinary retention
      C)
      Blood-tinged urine
      D)
      Highly concentrated urine
    2. A nurse is administering a powdered medication to a client. Which of the following actions should the nurse take first?
      A)
      Check the client for allergies.
      B)
      Document that the medication was administered.
      C)
      Mix the medication at the client's bedside.
      D)
      Determine the client's response to the medication.
    3. A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?
      A)
      Assess the pedal pulses with a Doppler device
      B)
      Assess the pedal pulses for a full minute
      C)
      Assess the apical pulse with a Doppler device
      D)
      Assess the apical pulse for a full minute
    4. A nurse is planning to administer an IM injection into a client's deltoid muscle. Which of the following actions should the nurse take?
      A)
      Inject the medication 12.7 cm (5 in) below the client's acromion process
      B)
      Use a 21-gauge needle for the injection
      C)
      Inject the medication at a 90-degree angle
      D)
      Inject a volume of less than 2 mL
    Page 6 of 12