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    Exam Review

    1. The nurse is giving report to the unlicensed assistive personnel on the care of four clients. The nurse should inform the unlicensed assistive personnel to avoid taking a rectal temperature for which client?
      A)
      Adult who underwent ileostomy surgery because of a perforated bowel
      B)
      Adult who develops thrombocytopenia after receiving chemotherapy treatments
      C)
      Adult who has a productive cough and is receiving oxygen by nasal cannula
      D)
      Adult who has hypothermia after being outside in a below zero temperature.
    2. A nurse is assisting in developing an in-service on the process of evidence-based practice. Which action should the nurse include as the first step of this process?
      A)
      Critically examine the evidence to determine if it is reliable.
      B)
      Question a current clinical practice that does not seem effective.
      C)
      Update policies to reflect new evidence-based guidelines.
      D)
      Locate research articles in current scientific journals.
    3. The nurse is observing the nursing student caring for the client with an artificial eye. What action by the student nurse would require intervention?
      A)
      Cleansing the prosthetic eye with normal saline solution
      B)
      Positioning the client lying down to remove the prosthetic eye
      C)
      Telling the client to remove the prosthetic eye weekly for cleaning
      D)
      Drying the prosthetic eye with gauze before reinsertion
    4. The client, who has a recurrence of breast cancer, questions the female nurse about treatment options. Which responses by the nurse would be appropriate? Select All That Apply.
      (SATA)
      A)
      I can arrange a conference for you and your family with the oncologist would that be okay?"
      B)
      "Is there something your oncologist told you about your options you don't understand?"
      C)
      "You should discuss your concerns with your oncologist I cannot give any medical advice." "know that if I had breast cancer, I would have both chemotherapy and radiation."
      D)
      "Have you asked for a second opinion yet? There might be other options for treatment."
    Page 1 of 32

    Exam Review

    1. A nurse is planning care for a client who requires bilateral arm restraints because the client is delirious and attempting to pull out a urinary retention catheter. Which information is important to consider when planning care for this client? Select All That Apply.
      (SATA)
      A)
      Use of restraints adequately prevents injuries.
      B)
      Laws permit the use of restraints when specific guidelines are followed.
      C)
      Reasons for use of restraints must be clearly documented.
      D)
      Most clients recognize that restraints contribute to their safety.
      E)
      Restraints needed in an emergency require a provider's prescription before application.
    2. A nurse is caring for a client being transferred from an acute care setting to a long-term care facility. Which information should the nurse include in the transfer report? Select All That Apply.
      (SATA)
      A)
      A list of the client's current self-care abilities and needs
      B)
      A description of the client's current medical status.
      C)
      A summary listing all medications received during the hospitalization
      D)
      A review of all physician orders throughout the hospitalization.
      E)
      A report of resolved and ongoing client problems
    3. The Emergency Department nurse is admitting a 58-year-old client with atypical chest pain. Which actions would the nurse delegate to the experienced unlicensed assistive personnel? Select All That Apply.
      (SATA)
      A)
      Check admission vital signs and record.
      B)
      Assess the client's level of chest pain.
      C)
      Assist the client in using the bathroom.
      D)
      Label and place the client's belongings in a plastic bag.
      E)
      Complete a 12-lead ECG for the client.
      F)
      Place the client on a continuous cardiac monitor.
      G)
      insert a saline lock and draw blood samples for the lab.
    4. A nurse is studying the recent increase in Type II diabetes in the community. Which factors should the nurse consider when examining the development of disease? Select All That Apply.
      (SATA)
      A)
      Environment
      B)
      Genetics
      C)
      Communication patterns
      D)
      Behavior of the community
      E)
      Lifestyle
    Page 2 of 32

    Exam Review

    1. A nurse is caring for an adolescent client with a seizure disorder who refuses to wear a medical alert bracelet. Which strategy could the nurse suggest to help convince the client to wear a medical alert bracelet?
      A)
      Select a bracelet like jewelry worn by peers.
      B)
      Ask friends to wear similar bracelets.
      C)
      Hide the bracelet under long-sleeved clothes.
      D)
      Wear the bracelet while engaging in contact sports.
    2. A nurse is assigned to four clients when arriving for the day shift. Which client should the nurse prioritize for assessment?
      A)
      A client who had an appendectomy and is receiving morphine sulfate and complains of nausea and pruritus
      B)
      A client with a urinary tract infection who is receiving intravenous antibiotics and has gross hematuria
      C)
      A client who received a loop diuretic for congestive heart failure and now complains of orthostatic symptoms.
      D)
      A client with gastroenteritis who has had emesis for 21 hours and now complains of muscle pain and weakness.
    3. The nurse manager is educating the nursing staff on how to differentiate among types of conflict. Which example should the nurse manager use for each type of conflict? For each example, click the type of conflict it correlates with.
      A)
      The nurse would like to go home rather than stay after shift to help the unit, but feels guilty about it.
      B)
      The staff nurse disagrees with the provider about the safety of discharging a client.
      C)
      The respiratory therapists disagree that nursing staff should make mechanical ventilation adjustments.
      D)
      The nursing staff are divided over a new overtime policy.
    4. A charge nurse is evaluating conflict resolution between two staff nurses. Which conflict resolution style is an example of both nurses giving up something to achieve a common goal?
      A)
      Accommodation.
      B)
      Collaboration.
      C)
      Avoidance.
      D)
      Compromising.
    Page 3 of 32

    Exam Review

    1. The nurse cares for four clients on the medical-surgical unit. Which tasks can the nurse delegate to the unlicensed assistive personnel (UAP)? Select All That Apply.
      A)
      Help a client ambulate initially after hip replacement.
      B)
      Provide a client with discharge instructions.
      C)
      Take vital signs on the client receiving an IV antibiotic.
      D)
      Ambulate the client who is two days post-op hysterectomy
      E)
      Start an IV in the client complaining of pain
    2. The nurse has just received the shift report. Which client should the nurse assess first?
      A)
      The client with a C-6 spinal cord injury who has autonomic dysreflexia
      B)
      The client with Huntington's disease who has writhing, twisting movements of the face
      C)
      The client with Guillain-Barré syndrome has ascending paralysis to the knees.
      D)
      The client with Parkinson's disease who is experiencing a "pill rolling" tremor
    3. A provider prescribes an oral medication for a client who is having some difficulty swallowing. What actions should the nurse take to prevent aspiration? Select All That Apply.
      A)
      Crush tablets that are crushable and mix with a small amount of applesauce.
      B)
      Have the client hyperextend the neck slightly when swallowing.
      C)
      Stroke under the chin over the larynx.
      D)
      Give water before, during, and after medication administration
      E)
      Have the client use a straw.
    4. The client is in the cardiac intensive care unit on dopamine, and BP increases to 210/130. Which action should the nurse take first?
      A)
      Assess the client's neurological status.
      B)
      Discontinue the client's dopamine.
      C)
      Administer hydralazine intravenously.
      D)
      Notify the client's healthcare provider.
    Page 4 of 32

    Exam Review

    1. A nurse is preparing to administer clindamycin 900 mg by intermittent IV bolus over 30 min. Available is clindamycin 900 mg in 100 mL dextrose 5% (DSW). 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.)
    2. A nurse is providing teaching to a client about healthy lifestyle changes. The client states. "I work long hours at work. I never have time for exercise or anything but fast food." Which goal should the nurse include in the client's nursing plan of care?
      A)
      The client will reduce weight by 4.5 kg (10 lb) within 2 weeks.
      B)
      The client will reduce daily stress and increase activity by exercising.
      C)
      The client will improve overall health by the next visit.
      D)
      The client will introduce two green vegetables into their diet by the end of the month.
    3. A nurse is delegating collection of a random stool specimen to an unlicensed assistive personnel (UAP). Which information should the nurse provide?
      A)
      Place chlorhexidine in the client's commode before they provide the sample.
      B)
      Double-bag the specimen if it must be placed in a refrigerator containing medication.
      C)
      Collect pus from the stool with a sterile swab and place it in a sterile test tube.
      D)
      Wrap the tongue blades used to retrieve the specimen in a paper towel before disposal.
    4. The registered nurse (RN) is working with a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP) to care for a group of clients. Which nursing tasks can the RN delegate or assign? Select All That Apply.
      A)
      Administering scheduled vaccinations
      B)
      The bed baths and oral care
      C)
      The routine oral medications for the clients
      D)
      Evaluating the client's progress
      E)
      Transporting a client to dialysis
    Page 5 of 32

    Exam Review

    1. A nurse is caring for a client who has pneumonia. Which tool should the nurse use to assist with providing cost-effective care?
      A)
      Chart audit
      B)
      Practice guideline
      C)
      Acuity rating.
      D)
      Critical pathway
    2. The staff nurse assesses erratic electrical activity on the telemetry monitor while the client is speaking to the nurse via the intercom system. Which task should the nurse instruct the unlicensed assistive personnel to implement?
      A)
      Call a Code Blue immediately.
      B)
      Check the client's telemetry leads.
      C)
      Remove the telemetry monitor.
      D)
      Find the nurse to check the client.
    3. Two staff nurses ask a charge nurse to help resolve a conflict over holiday scheduling. Which action should the charge nurse take?
      A)
      Encourage each staff nurse to give up something as part of the negotiation.
      B)
      Explain to the staff nurses that the holiday schedule is non-negotiable.
      C)
      Compliment one of the nurses in private on their flexibility and thank them for working all the holidays.
      D)
      Negotiate with the two staff nurses at the nurses' station.
    4. A nurse has shared their computer username and password with a student nurse who is assisting with client care. Of the possible consequences associated with sharing this information, which has the most significance?
      A)
      The nurse has violated civil law.
      B)
      The nurse has violated hospital policy.
      C)
      The nurse has not used good professional judgment.
      D)
      The nurse can be prosecuted as a criminal.
    Page 6 of 32