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    Exam Review

    1. A nurse is caring for a client who has schizophrenia and is experiencing hallucinations. The provider prescribes chlorpromazine 50 mg IM every 4 hr as needed. Available is chlorpromazine injection 25 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
      Correct Answer:2 mL per dose
    2. A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following actions is an example of a violation of confidentiality?
      A)
      Reporting laboratory findings to a member of the client's family
      B)
      Discussing a client's surgical procedure with the nurse manager
      C)
      Notifying the provider of physical examination findings
      D)
      Identifying the client by name when making a referral for home health services
    3. A nurse is caring for a client whose family is in a state of disagreement over the care of their family member. The nurse should report the situation to which of the following facility personnel?
      A)
      Hospital ethics committee
      B)
      Hospital administrator
      C)
      Clinical education specialist
      D)
      Quality improvement committee
    4. A nurse is administering several medications via a client's gastrostomy tube. At which of the following times should the nurse instill 15 to 30 mL of warm water? (Select all that apply.)
      (SATA)
      A)
      Before aspirating gastric contents
      B)
      Prior to administering each medication
      C)
      After each medication
      D)
      When the flow of the medication by gravity slows
      E)
      After giving multiple medications
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    Exam Review

    1. A nurse is preparing to administer 0.45% sodium chloride (NaCl) 2000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
      Correct Answer:250 mL/hr
    2. 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)
      Surgical suite nurse
      B)
      Surgeon
      C)
      Nurse
      D)
      Anesthesiologist
    3. A nurse accidentally administers the wrong medication to a client, which results in a severe allergic reaction and prolongs the client's hospitalization. The client could rightfully sue the nurse for which of the following?
      A)
      Malpractice
      B)
      Battery
      C)
      Abuse
      D)
      Assault
    4. A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation?
      A)
      "Documentation allows providers to monitor the nurse's activities."
      B)
      "Documentation is a communication tool for the interprofessional health care team."
      C)
      "Documentation provides information to the client about financial charges for care provided."
      D)
      "Documentation provides information for a client audit."
    Page 2 of 13

    Exam Review

    1. A nurse is administering timolol eye drops to a client who has glaucoma. Which of the following actions should the nurse take?
      A)
      Protect the distal portion of the eyedropper using clean technique.
      B)
      Apply pressure to the bridge of the nose after administration.
      C)
      Wipe the eye from the outer canthus to the inner canthus before instillation.
      D)
      Drop prescribed amount of medication into the conjunctival sac.
    2. A nurse is implementing direct nursing care for a group of clients in an acute care facility. Which of the following actions by the nurse is considered an indirect nursing care activity?
      A)
      Assigning tasks to an assistive personnel (AP)
      B)
      Providing anticipatory guidance to a client in crisis
      C)
      Determining the client's length of stay
      D)
      Establishing the client's secondary medical diagnoses
    3. A nurse on a medical unit is planning care for an older adult client who takes several medications. Which of the following prescribed medications places the client at risk for orthostatic hypotension? (Select all that apply.)
      A)
      Furosemide
      B)
      Telmisartan
      C)
      Atorvastatin
      D)
      Duloxetine
      E)
      Clopidogrel
    4. A nurse is preparing to administer amoxicillin 350 mg PO. Available is amoxicillin 250 mg/5 mL. How many mL should the nurse administer? (Round to the nearest whole number.)
    Page 3 of 13

    Exam Review

    1. A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching?
      A)
      The client waits 10 min between inhalations.
      B)
      The client takes a quick inhalation while releasing the medication from the inhaler.
      C)
      The client holds his breath for 10 seconds after inhaling the medication.
      D)
      The client exhales as the medication is released from the inhaler.
    2. A nurse is teaching a class about safe medication administration. The nurse should include in the teaching that which of the following references are acceptable for safe medication administration? (Select all that apply.)
      A)
      Published journals
      B)
      Pharmaceutical sales representatives
      C)
      A website that ends in .com
      D)
      Physicians Desk Reference
      E)
      Pharmacists
    3. A nurse is giving change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR?
      A)
      Code status
      B)
      Plan of care charges for upcoming shift
      C)
      Intracranial pressure readings
      D)
      Glasgow results
    4. A nurse is providing discharge teaching to a client who has a new prescription for a metered dose inhaler (MDI). Which of the following instructions should the nurse include in the teaching?
      A)
      Shake the inhaler for 3 to 5 seconds.
      B)
      Rinse the mouth with mouthwash after inhaling the medication.
      C)
      Wait 2 min between inhalations.
      D)
      Press down twice on the MDI canister.
    Page 4 of 13

    Exam Review

    1. A nurse is preparing to administer Ringer's lactate 500 mL IV bolus to infuse over 3 hr. The drop factor of the manual IV tubing is 20 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
    2. A nurse is teaching a class about medication reconciliation. Which of the following information should the nurse include in the teaching?
      A)
      Provide a list of the client's current medications during the change of shift report.
      B)
      Provide a list of the client's current medications during admission to a health care facility.
      C)
      Do not perform reconciliation for a client at discharge from a health care facility.
      D)
      Do not include over-the-counter medications in the medication reconciliation report.
    3. A nurse is preparing to transfuse one unit of packed RBC to a client who experienced a mild allergic reaction during a previous transfusion. The nurse should administer diphenhydramine prior to the transfusion for which of the following allergic responses?
      A)
      Hemolysis
      B)
      Urticaria
      C)
      Fever
      D)
      Fluid overload
    4. A nurse is planning to discharge a client who has quadriplegia to his home. The nurse suggests that the family might need respite care services. When a family member asks how respite care can help, which of the following responses should the nurse provide?
      A)
      "Respite care provides holistic support and care for a client who is terminally ill."
      B)
      “Respite care helps relieve pain and promote comfort.”
      C)
      "Respite care is a continuation of psychological support after a family member dies."
      D)
      "Respite care allows the primary caregiver time away from day-to-day care responsibilities."
    Page 5 of 13

    Exam Review

    1. A nurse is completing the initial admission assessment and history for a client. Which of the following is the priority action for the nurse to take?
      A)
      Provide a schedule of visiting hours to the client's family.
      B)
      Develop a plan of care for the client.
      C)
      Document the client's allergies in the electronic medical record.
      D)
      Teach the client about his diagnosis.
    2. A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?
      A)
      Petechiae
      B)
      Cyanosis
      C)
      Blood pressure
      D)
      Nausea
    3. 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.)
      A)
      Facility room number
      B)
      Client's full name
      C)
      Provider's name
      D)
      Partner's full name
    4. A nurse is teaching a class on health promotion and illness prevention. The nurse should include that which of the following is an example of secondary prevention?
      A)
      Referring a client who has had a mastectomy to a support group
      B)
      Providing a community program on stress reduction
      C)
      Teaching foot care to a client who has diabetes
      D)
      Performing monthly breast self-examinations
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