Exam Review

A nurse is caring for a client who has nausea and is vomiting. The nurse should identify the client is at risk for which of the following acid-base imbalances?
A)
Respiratory acidosis.
B)
Metabolic alkalosis.
C)
Respiratory alkalosis.
D)
Metabolic acidosis.
A nurse has received change-of-shift report on a group of clients and is preparing her assignment. Which of the following clients should the nurse assess first?
A)
A client who has pneumonia and was treated for a temperature of 38.9 C (102 F) at 0400.
B)
A client who had a blood glucose reading at 0650 of 70 mg/dL after receiving 50
C)
A client who has pulled out the peripheral IV catheter and is scheduled to receive a dose of famotidine at 0800.
D)
A client who was admitted for chest pain and is reporting a new onset of indigestion.
A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse?
A)
Auscultates bowel sounds for 3 to 5 minutes.
B)
Palpates the abdomen prior to performing auscultation.
C)
Clamps the NG tube during auscultation.
D)
Performs auscultation between meals.
A nurse should understand that which of the following is an example of the health promotion and self-care family function and structure?
A)
Families learning about the importance of budgeting.
B)
Families learning about the importance of taking care of their health.
C)
Parents providing basic needs of food and shelter to their family.
D)
Parents teaching their children how to fit into the social environment.

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Exam Review

A nurse is reviewing a client's lab results. Which of the following lab values should the nurse report to the provider?
A)
Chloride 99 mEq/L.
B)
Potassium 3.6 mEq/L.
C)
Sodium 126 mEq/L.
D)
Magnesium 1.9 mEq/L.
A nurse is caring for a client who reports back pain. The nurse asks the client to rate the pain on a scale of 0 to 10. The nurse is using which of the following components of the PQRST Mnemonic?
A)
Severity.
B)
Quality.
C)
Region.
D)
Precipitating cause.
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 press the patch securely in place on my forearm.
C)
I will remove the old patch and apply a new one in the same location.
D)
I will use lotion on irritated skin before applying a new patch in that area.
A nurse is assessing a client for manifestations of pain. Which of the following findings is an objective indicator of pain?
A)
The client rates their pain as an 8 on a scale of 0 to 10.
B)
The client states the pain is located on their abdomen.
C)
The client reports a burning sensation.
D)
The client grimaces when they move.

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Exam Review

A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?
(SATA)
A)
Bradycardia.
B)
Pale yellow urine.
C)
Hypotension.
D)
Poor skin turgor.
E)
Flat neck veins.
A nurse in a pediatric unit is planning care for a group of clients. Which of the following clients should the nurse plan to use the Crying, Requires oxygen, Increased vital signs, Expression, Sleeplessness (CRIES) pain scale?
A)
A 4-day-old infant who had a repair of a birth defect.
B)
A 10-year-old client who had an appendectomy.
C)
A 4-year-old preschooler who had a tonsillectomy.
D)
A 3-year-old toddler who has a broken elbow.
A nurse is administering a medication to a client for acute pain. Of the various routes for drug administration, which would be chosen because it is absorbed most rapidly?
A)
Injected medications.
B)
Oral-coated medications.
C)
Topical skin medications.
D)
Liquid oral medications.
A nurse is caring for a client who has dyspnea, slight cyanosis, and a respiratory rate of 28/min. During which of the following phases of the nursing process will the nurse determine that the client has impaired gas exchange?
A)
Diagnosis.
B)
Assessment.
C)
Planning.
D)
Evaluation.

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Exam Review

A nurse is assessing a client who has a pleural effusion. Which of the following findings should the nurse expect?
A)
Dullness percussed over the client's lung fields.
B)
Crepitus palpated on the client's chest.
C)
Substernal retractions noted on the client's chest.
D)
Crackles auscultated over the client's lung fields.
A nurse is admitting a new client. Which of the following steps of the nursing process is the nurse performing when formulating goals for a positive outcome?
A)
Planning.
B)
Assessment.
C)
Implementation.
D)
Evaluation.
A nurse is administering a medication that is formulated as enteric-coated tablets. What is the rationale for not crushing or chewing enteric-coated tablets?
A)
To prevent gastric irritation.
B)
To prevent absorption in the mouth.
C)
To facilitate absorption in the stomach.
D)
To prevent absorption in the esophagus.
A nurse is caring for a client who reports abdominal pain. The nurse asks the client to describe what the pain feels like. The nurse is using which of the following components of the PQRST mnemonic?
A)
Quality.
B)
Severity.
C)
Precipitating cause.
D)
Region.

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Exam Review

A nurse is preparing a teaching plan for a client who speaks limited English and is scheduled for a surgical procedure. Which of the following guidelines should the nurse plan to use when selecting written educational materials for the client? (Select all that apply.)
A)
Use materials written in the client's spoken language.
B)
Use pictures.
C)
Use culturally diverse materials.
D)
Provide a variety of educational materials.
E)
Use materials written at an eighth-grade level.
A nurse is providing teaching for a client who has a prescription for home oxygen. Which of the following instructions should the nurse include? (Select all that apply.)
A)
Post a "No Smoking" sign inside the home.
B)
Notify the fire department that oxygen is used in the home.
C)
Attach oxygen containers to a fixed object.
D)
Ensure oxygen tubing is no longer than 60 feet in length.
E)
Store spare oxygen containers in a closet.
A nurse is assessing a client who has oxygen toxicity. Which of the following findings should the nurse expect?
A)
Facial flushing.
B)
Muscle twitching.
C)
Periorbital edema.
D)
Metallic taste in mouth.
A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first?
A)
Notify the nurse manager.
B)
Call the client's provider.
C)
Complete an incident report.
D)
Assess the client.

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Exam Review

A nurse is teaching the parents of a child who is to start using a metered-dose inhaler (MDI) to treat asthma. Which of the following information should the nurse include in the teaching?
A)
Cover exhalation slots of the spacer with lips when inhaling.
B)
The spacer increases the amount of medication delivered to the oropharynx.
C)
The spacer increases the amount of medication delivered to the lungs.
D)
Inhale rapidly using the spacer with the MDI.
A nurse is teaching a client about maintaining skin integrity to decrease the risk of infection. Which of the following instructions should the nurse include?
A)
Wash your skin daily with hot water.
B)
Allow your skin to air dry after bathing.
C)
Use a moisturizer on your skin after cleaning.
D)
Rub your skin firmly when cleaning.
A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers?
A)
The left fifth intercostal space at the midclavicular line.
B)
The right second intercostal space.
C)
The left second intercostal space.
D)
The left fifth intercostal space at the anterior axillary line.
A nurse is teaching a newly licensed nurse about a nonrebreather oxygen mask. Which of the following instructions should the nurse include?
A)
Use a nonrebreather mask to deliver low-flow oxygen.
B)
A nonrebreather mask should fit snugly over a client's face.
C)
A nonrebreather mask dries a client's mucous membranes.
D)
The reservoir bag on a nonrebreather mask should collapse with exhalation.

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