Exam Review

A nurse is preparing to teach a client who has a low literacy level. Which of the following methods should the nurse plan to include?
A)
Emphasize four important points at each session.
B)
Have short teaching sessions.
C)
Refer to the client in the third person during the session.
D)
Use a passive voice to explain the information.
A nurse is completing a client assessment for admission to the medical unit. Which of the following abdominal assessment findings require further investigation by the nurse?
A)
Bilateral bowel sounds in lower quadrants
B)
Symmetrical convex sphere shape
C)
Ecchymosis
D)
Concave umbilicus
A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?
A)
Document that the nurse was unable to measure the client's temperature.
B)
Wait 30 min and return to measure the oral temperature
C)
Proceed to measure the oral temperature.
D)
Provide the client a sip of warm water, wait 5 min, and measure the temperature.
A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds?
A)
Wheezes
B)
Rhonchi
C)
Crackles
D)
Stridor

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Exam Review

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?
A)
Dorsal surface of the foot
B)
Conjunctivae
C)
Dorsal surface of the hand
D)
Pinnae of the ears
A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?
A)
Testing visual acuity
B)
Eliciting the gag reflex
C)
Checking the pupillary response to light
D)
Observing for facial symmetry
A nurse is observing a newly licensed nurse prepare a sterile field. For which of the following actions should the nurse intervene?
A)
Wears sterile gloves when moving sterile items on the sterile field.
B)
Positions the wrapped package on the bedside table so the outer flap is away from her.
C)
Holds gauze packages 15 cm (6 in) above the sterile field.
D)
Holds a bottle of solution with the label away from the palm of the hand.
A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse use to promote this discussion?
A)
"Would it help to discuss your feelings about this hospitalization?"
B)
"What brought you to the hospital?"
C)
"Would you tell me about all of your medical issues?"
D)
"Do you want to talk about your health concerns?"

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Exam Review

A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client?
A)
Contact
B)
Droplet
C)
Protective
D)
Airborne
A nurse is providing nail care for a client. Which of the following actions should the nurse take?
A)
File the nails in a rounded shape.
B)
Clean under the nail with an orange stick
C)
Push the cuticles back with a metal nail file.
D)
Trim the nails at the lateral corners.
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)
Massage bony prominences to promote circulation.
C)
Reposition the client every 3 hr.
D)
Apply cornstarch to keep the skin dry.
A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?
A)
Elevate the head of the bed no more than 45°.
B)
Use a transfer device to lift the client up in bed.
C)
Apply cornstarch to keep sensitive skin areas dry.
D)
Massage the skin over the client's bony prominences.

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Exam Review

A nurse is admitting a client who has hepatitis C. Which of the following precautions should the nurse implement?
A)
Contact
B)
Standard
C)
Droplet
D)
Airborne
A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply?
A)
Wet-to-dry gauze dressing
B)
Transparent dressing
C)
Hydrogel dressing
D)
Alginate dressing
A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full thickness wound with jagged edges and muscle tissue visible. The nurse should documents this as which of the following types of wounds?
A)
Abrasion
B)
Laceration
C)
Puncture
D)
Contusion
A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?
A)
Motor impairment
B)
Pain
C)
The client's culture
D)
Hearing loss

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Exam Review

A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include?
A)
"Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds."
B)
"If you wear gloves, you do not have to wash your hands."
C)
"If you don't have an infection, your hands won't infect others."
D)
"Use an alcohol rub when your hands are visibly soiled."
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
A)
WBC count
B)
BUN
C)
Potassium
D)
RBC count
A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material?
A)
Enclose the dressing in a single clear plastic bag and discard in the bedside trash receptacle.
B)
Double-bag the dressing in clear bags and label it "biohazard".
C)
Discard the dressing in the bedside trash receptacle.
D)
Dispose of the dressing in a biohazardous waste container.
A nurse is preparing a presentation at a senior center about age-related musculoskeletal changes. Which of the following changes should the nurse plan to include?
A)
Decreased muscle mass
B)
Reduced chest width
C)
Thickened vertebral disks
D)
Increased force of isometric contraction

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Exam Review

A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction?
A)
Checks the instrument gauge to ensure the reading starts at zero
B)
Places the client's arm above the level of the client's heart
C)
Wraps the blood pressure cuff snugly around the client's arm
D)
Centers the cuff bladder over the client's brachial artery
A nurse is assessing a client's abdomen who reports stomach pain. Which of the following actions should the nurse take first?
A)
Inspect
B)
Palpate
C)
Auscultate
D)
Percuss
A nurse is admitting a client who requires droplet precautions due to influenza. Which of the following actions should the nurse take?
A)
Place the client in a room with negative airflow.
B)
Wear a gown when providing care to the client.
C)
Ensure the client's room has HEPA filtration.
D)
Wear a mask when providing care to the client.
Which division of the United States Department of Health and Human Services is primarily responsible for the administrative provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)?
A)
Administration for Children and Families
B)
Centers for Medicare and Medicaid Services
C)
Social Security Administration
D)
Health Resources and Services Administration

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