Exam Review

A registered nurse interprets that a scribbled medication order reads 25 mg. The nurse administers 25 mg of the medication to a patient and then discovers that the dose was incorrectly interpreted and should have been 15 mg. Who is ultimately responsible for the error?
A)
Nurse
B)
Health care provider
C)
Hospital
D)
Pharmacist
A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?
A)
Uses a microwave for cooking.
B)
Handrails are present in the bathroom.
C)
Electrical cords are placed along the walls.
D)
Scatter rugs are present in the kitchen.
A nurse is completing a client history and physical examination. Which of the following information should the nurse consider subjective data?
A)
Petechiae
B)
Blood pressure
C)
Nausea
D)
Cyanosis
A nurse is assessing a patient with activity intolerance for possible orthostatic hypotension. Which finding will help confirm orthostatic hypotension?
A)
Blood pressure sitting 140/60; blood pressure 130/60 standing
B)
Blood pressure sitting 130/60; blood pressure 110/60 standing
C)
Blood pressure sitting 126/64; blood pressure 120/58 standing
D)
Blood pressure sitting 130/64; blood pressure 140/70 standing

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Exam Review

The nurse is emptying an ileostomy pouch for a patient. Which assessment finding will the nurse report immediately?
A)
Continuous output from the stoma
B)
Presence of blood in the stool
C)
Malodorous stool
D)
Liquid consistency of stool
A nurse is admitting a client who is dehydrated. Which BUN level should the nurse expect the client to have upon admission (Normal BUN 10-20)?
A)
165 mg/dL
B)
35 mg/dL
C)
10 mg/dL
D)
31 mg/dL
A nurse is teaching a client who has left hemiparesis how to use a cane. Which of the following instructions should the nurse include?
A)
Hold the cane on the right side to provide support for the weaker leg
B)
Remove the rubber tip when using the cane.
C)
Advance the right leg and the cane together to support the weaker leg
D)
Place the cane approximately 61 cm (24 in) in front of her feet before advancing
The nurse is caring for a client with full hearing loss. What should the nurse recommend for the home environment?
A)
Have the client move in with a family member or close friend.
B)
Encourage the client to get a roommate.
C)
Increase the sound on all alarms.
D)
Install flashing lights for alarms.

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Exam Review

A nurse is assessing a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?
A)
Intact skin with localized erythema.
B)
Full-thickness skin loss with visible adipose tissue.
C)
Partial-thickness skin loss with red tissue in wound bed.
D)
Full-thickness skin loss with visible bone.
A nurse is caring for a client who sustained blood loss. Which is a manifestation of hypovolemia?
A)
Dyspnea
B)
Increased blood pressure
C)
Weak pulse
D)
Decreased heart rate
A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client’s skin?
A)
Provide the client with a diet high in protein.
B)
Reposition the client every 3 hours.
C)
Massage bony prominences to promote circulation.
D)
Apply cornstarch to keep the skin dry.
A small-bore feeding tube is placed. Which technique will the nurse use to best verify tube placement?
A)
Auscultation
B)
X-ray
C)
Aspiration of contents
D)
pH testing

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Exam Review

A patient refuses medication. Which is the nurse’s first action?
A)
Discreetly hide the medication in the patient’s favorite gelatin.
B)
Agree with the patient’s decision and document it in the chart.
C)
Explore with the patient reasons for not wanting to take the medication.
D)
Educate the patient about the importance of the medication.
A nurse is caring for a client who is postoperative following abdominal surgery. The nurse discovers a loop of bowel through an opening in the surgical incision. Which of the following actions should the nurse take?
A)
Place the head of the client’s bed in the flat position.
B)
Gently reinsert the bowel back into the client’s wound.
C)
Position the client on his left side.
D)
Apply moistened sterile gauze to the site.
A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client’s skin?
A)
Provide the client with a diet high in protein.
B)
Reposition the client every 3 hours.
C)
Massage bony prominences to promote circulation.
D)
Apply cornstarch to keep the skin dry.
A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?
A)
Check the client’s skin every 8 hours for signs of breakdown.
B)
Clean the client’s skin and perineum with hot water after each episode of incontinence.
C)
Apply a moisture barrier ointment to the client’s skin.
D)
Request a prescription for the insertion of an indwelling urinary catheter.

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Exam Review

A nurse is preparing an in-service program about preventing medication errors when transcribing a prescription. The nurse is using a dosage example of two tenths of a milligram. Which of the following examples should the nurse use to show appropriate transcription of this dosage?
A)
20 mg
B)
0.20 mg
C)
0.2 mg
D)
2.0 mg
A nurse is performing an admission assessment on a client. Which finding should the nurse identify as an indication that the client is dehydrated?
A)
Blood pressure 178/90 mm Hg
B)
Jugular vein distention
C)
Heart rate 50
D)
Skin tenting present
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)
Changing the client’s bed linens each day
C)
Placing the client in a room with positive-pressure airflow
D)
Performing hand hygiene before, during, and after direct contact with the client
A nurse is providing care for a client who has a prescription for home oxygen. Which of the following instructions should the nurse include?
A)
Post a “No Smoking” sign in the home.
B)
Attach oxygen containers to a fixed object.
C)
Store spare oxygen tanks in a closet.
D)
Notify the fire department that oxygen is used in the home.
E)
Ensure oxygen tubing is no longer than 60 feet in length.

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Exam Review

While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first?
A)
Request the risk manager obtain consent for HIV testing from the client.
B)
Complete an incident report.
C)
Wash the site of injury with soap and water.
D)
Consent to post-exposure treatment with antiretroviral medications.
The nurse is administering medication to a pregnant patient. After looking up the medication, the nurse determines the medication is categorized as a Pregnancy Risk Category A. What is true of Pregnancy Risk Category A drugs?
A)
Benefit may outweigh the risk.
B)
Studies show fetal risk.
C)
Contraindicated in pregnant women.
D)
Fetal harm is unlikely.
The nurse is preparing to administer medications to two patients with the same last name. After the administration, the nurse realizes that she did not check the identification of the patient before administering medication. Which action should the nurse complete first?
A)
Complete proper documentation of the medication error in the patient’s chart.
B)
Return to the room to check and assess the patient.
C)
Administer the antidote to the patient immediately.
D)
Alert the charge nurse that a medication error has occurred.
A nurse is assessing a client who has hypoxemia for a late sign. Which finding should the nurse expect?
A)
Hypertension
B)
Tachycardia
C)
Pallor
D)
Bradypnea

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