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    Exam Review

    1. A nurse is receiving change-of-shift report at the start of the shift. Which of the following statements by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)?
      A)
      "The client works in the hospital radiology department."
      B)
      "The client discussed having prior thoughts of suicide."
      C)
      "The client's blood pressure and pulse have been fluctuating throughout the day."
      D)
      "The client's family members have been present most of the day."
    2. A nurse is supervising a newly licensed nurse who is caring for a client on a behavioral health unit. Exhibits Complete the following sentence by using the list of options. The nurse should instruct the newly licensed nurse to first ▾ provide continuous monitoring of this client then ▾ obtain provider prescription for seclusion or restraints.
      Dropdown 1:
      Option 1: conduct a neurosensory check every 2 hours
      Option 2: assess for readiness for release from seclusion
      Option 3: provide continuous monitoring of this client
      Option 4: clearly document reason for seclusion
      Dropdown 2:
      Option 1: obtain provider prescription for seclusion or restraints
      Option 2: provide means for hygiene and elimination
      Option 3: discuss reason for seclusion with client
      Option 4: offer food and fluids
    3. A nurse manager observes an unknown man in a laboratory coat making copies of a client's medical record. Which of the following actions should the nurse plan to take first?
      A)
      Report the observation to the nurse caring for that client.
      B)
      Inform the nursing supervisor.
      C)
      Approach the man and ask why he is making copies.
      D)
      Notify hospital security.
    4. A nurse is planning to assign care activities to the assistive personnel (AP) on her team. Which of the following activities can the nurse assign to the AP? (Select all that apply.)
      (SATA)
      A)
      Check the position of a client in soft wrist restraints.
      B)
      Accompany a client who has depression to occupational therapy.
      C)
      Set limits with a client who has mania.
      D)
      Sit with a client who has alcohol use disorder and whose last drink was five days ago.
      E)
      Assess a client who has hypomania for exhaustion.
    Page 1 of 30

    Exam Review

    1. A nurse is planning to assign tasks for a group of clients. Which of the following tasks should the nurse plan to assign to an assistive personnel (AP)? (Select all that apply.)
      (SATA)
      A)
      Ambulate an older adult client who has hypertension.
      B)
      Provide discharge instructions for a client who has a new skin graft.
      C)
      Check a blood product with another nurse prior to administration.
      D)
      Weigh a client who has heart failure.
      E)
      Perform an admission assessment on a client.
    2. A nurse suspects that a coworker is diverting opioid analgesics. Which of the following is an adverse effect of opioid medications?
      A)
      Dilated pupils
      B)
      Euphoria
      C)
      Rhinorrhea
      D)
      Hallucinations
    3. A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent?
      A)
      The client
      B)
      The client's son, who has a durable power of attorney
      C)
      The client's partner
      D)
      The client's daughter, who is the primary caregiver
    4. A nurse is caring for a client who is postoperative. Exhibits Which of the following should the nurse request as a recommendation in an SBAR report to the provider? Select All That Apply
      (SATA)
      A)
      Medication for elevated temperature
      B)
      Insertion of NG tube for decompression
      C)
      Oxygen 2 to 4 L/min via nasal cannula
      D)
      Insertion of urinary catheter
      E)
      Evaluation of surgical wound drain
    Page 2 of 30

    Exam Review

    1. A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?
      A)
      A client who has Guillain-Barre syndrome
      B)
      A client who has a lumbosacral spinal tumor
      C)
      A client who has systemic sclerosis
      D)
      A client who has amyotrophic lateral sclerosis (ALS)
    2. A nurse manager is reviewing the admission history of four adults who were admitted to the medical-surgical unit during the shift. Which of the following situations is the nurse required to disclose information to an outside agency about the client or the client's circumstances?
      A)
      A young adult client admitted for acute glomerulonephritis following a viral infection
      B)
      A dependent adult admitted for the treatment of a spiral fracture
      C)
      A young adult client admitted for asthma and has track marks that may indicate IV drug abuse
      D)
      An emancipated minor who has acute appendicitis and wants to leave the facility without treatment
    3. A charge nurse is planning to conduct a performance appraisal of a staff member on her unit. Which of the following actions should the nurse take?
      A)
      Inform the staff member of her appraisal time for that day prior to change-of-shift report.
      B)
      Schedule the appraisal interview as early in the shift as possible.
      C)
      Provide the staff member with a copy of the appraisal form in advance.
      D)
      Provide a chair directly across the desk for the staff member to sit in.
    4. A nurse has received morning report on the following four clients. Which of the following clients should the nurse assess first?
      A)
      A client who was administered erythromycin for acute glomerulonephritis and reports reddish-brown urinary output
      B)
      A client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dL
      C)
      A client who was administered adalimumab for Crohn's disease, has a serum calcium level of 10 mg/dL, and reports a headache
      D)
      A client who was administered acyclovir for cellulitis reports pain in the affected leg
    Page 3 of 30

    Exam Review

    1. An RN is delegating care activities to a licensed practical nurse (LPN). Which of the following is the priority criterion the RN should consider when delegating?
      A)
      Agency policies for the LPN
      B)
      The documented experience level of the LPN
      C)
      The documented skill level of the LPN
      D)
      State Nurse Practice Act for the LPN
    2. A nurse is teaching a class on torts. The nurse should include which of the following situations as an example of negligence?
      A)
      A client who is alert and oriented makes an informed decision to leave the hospital against medical advice. The nurse applies restraints to the client to prevent him from leaving.
      B)
      A nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning and reports it to the provider in the early afternoon.
      C)
      A client who is competent refuses an antidepressant medication. The nurse dissolves the medication in food and administers it to her without her knowledge.
      D)
      A nurse finds a client who is on a low-sodium diet eating salted potato chips. The nurse tells the client that she will apply wrist restraints if he does not stop eating the potato chips.
    3. A nurse on a medical-surgical unit is providing care for a group of clients. The nurse should delegate collection of which of the following specimens to the assistive personnel (AP)?
      A)
      Blood for PaCO2
      B)
      Random stool specimen
      C)
      Wound drainage for culture
      D)
      Urine from an indwelling catheter
    4. A nurse is planning to use the SBAR communication tool when calling a provider. Which of the following statements should the nurse include in the B step?
      A)
      "There are no provider's prescriptions available."
      B)
      "The client was found unconscious on the floor in her home."
      C)
      "The client should be seen by a neurologist."
      D)
      "The client is disoriented. Pupils are slow to respond to light."
    Page 4 of 30

    Exam Review

    1. A nurse is caring for four postoperative clients. The nurse can delegate obtaining vital signs to an assistive personnel (AP) for which of the following clients?
      A)
      A client who is 3 days postoperative following a craniotomy
      B)
      A client who is 3 days postoperative following gastric bypass surgery
      C)
      A client who is 2 hr postoperative following an abdominal hysterectomy
      D)
      A client who is 1 hr postoperative following a thyroidectomy
    2. A nurse on a pediatric unit is reviewing her client assignment following the shift report. Which of the following clients should the nurse plan to assess first?
      A)
      An infant who has pertussis and is receiving oxygen via nasal cannula
      B)
      An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions
      C)
      A school-age child who has diabetes mellitus and requires blood glucose monitoring
      D)
      A toddler who has both arms in casts and needs to be fed his breakfast
    3. An assistive personnel (AP) reports to the nurse that a client who is 3 days postoperative following an abdominal hysterectomy has a dressing that is saturated with blood. Which of the following tasks should the nurse delegate to the AP?
      A)
      Palpate for possible bladder distention.
      B)
      Observe the incision site.
      C)
      Change the abdominal dressing.
      D)
      Obtain vital signs.
    4. A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first?
      A)
      Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate.
      B)
      Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma.
      C)
      Collect a stool sample for ova and parasites from a school-age child
      D)
      Engage a toddler in play.
    Page 5 of 30

    Exam Review

    1. A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first?
      A)
      Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate.
      B)
      Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma.
      C)
      Collect a stool sample for ova and parasites from a school-age child
      D)
      Engage a toddler in play.
    2. A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse's priority?
      A)
      A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6
      B)
      A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous
      C)
      A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL
      D)
      A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg
    3. A nurse on the pediatric unit is providing room assignments for children who are to be admitted to the unit. The nurse should plan to place a child who is postoperative from an appendectomy with which of the following clients?
      A)
      A child who is experiencing sickle cell crisis
      B)
      A child who has a head injury
      C)
      A child who has a new diagnosis of type 1 diabetes mellitus
      D)
      A child who has streptococcal pharyngitis
    4. A charge nurse plans to use effective change strategies when implementing a change in a nursing procedure on the medical-surgical unit. Which of the following actions should the charge nurse take during the moving stage of change?
      A)
      Set a target date.
      B)
      Use tactics to alert staff nurses that a change is needed.
      C)
      Evaluate the effectiveness of the change.
      D)
      Assess the problem.
    Page 6 of 30