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    Exam Review

    1. A nurse instructs a female client about collecting a midstream urine sample. Which of the following client statements indicates an understanding of the procedure?
      A)
      I'll use each cleansing wipe twice.
      B)
      I'll urinate a little then stop.
      C)
      I'll clean the inside of the container with a wipe.
      D)
      I'll use the cleansing wipe from front to back.
    2. As part of an annual physical examination, a nurse is preparing a client to undergo a chest x-ray. Which of the following instructions should the nurse give the client prior to the procedure?
      A)
      Remove all metal necklaces.
      B)
      Take several shallow breaths during the procedure.
      C)
      Do not eat or drink anything the morning of the test.
      D)
      Expect minor discomfort after the procedure.
    3. As part of an annual physical examination, a nurse is preparing a client to undergo a chest x-ray. Which of the following instructions should the nurse give the client prior to the procedure?
      A)
      Remove all metal necklaces.
      B)
      Take several shallow breaths during the procedure.
      C)
      Do not eat or drink anything the morning of the test.
      D)
      Expect minor discomfort after the procedure.
    4. A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first?
      A)
      Administer the medication.
      B)
      Reposition the client.
      C)
      Review the effects of the pain medication.
      D)
      Determine the location of the pain.
    Page 1 of 24

    Exam Review

    1. A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?
      A)
      Hold the hands higher than the elbows.
      B)
      Rub hands and arms to dry.
      C)
      Adjust the water temperature to feel hot.
      D)
      Apply 4 to 5 ml of liquid soap to the hands.
    2. A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?
      A)
      Partial-thickness skin loss
      B)
      Necrotic subcutaneous tissue
      C)
      Exposed bone
      D)
      Blood-filled blisters
    3. 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)
      Apply cornstarch to keep the skin dry
      B)
      Reposition the client every 3 hours
      C)
      Massage bony prominences to promote circulation
      D)
      Provide the client with a diet high in protein
    4. A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take?
      A)
      Make sure the room temperature is cool
      B)
      Provide music as an environmental distraction
      C)
      Inform the client that the provider will examine sensitive areas first
      D)
      Explain to the client what is about to happen
    Page 2 of 24

    Exam Review

    1. A nurse is teaching a client who reports insomnia about promoting rest and sleep. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
      A)
      I will have a cup of hot cocoa immediately before bedtime
      B)
      I will walk briskly for 30 minutes before bedtime
      C)
      I will do my muscle relaxation techniques each afternoon
      D)
      I will no longer have a glass of wine before bedtime
    2. A nurse is preparing to assist a client who can partially bear weight and is cooperative with transfer from the bed to a chair. Which of the following actions should the nurse take to maintain safety during the transfer?
      A)
      Enlist help from another staff member
      B)
      Avoid movements that twist the spine
      C)
      Use a powered standing-assist lift
      D)
      Adjust the bed to an appropriate height
    3. A nurse is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. Which of the following infection-control precautions should the nurse use while caring for this client?
      A)
      Contact
      B)
      Airborne
      C)
      Neutropenic
      D)
      Droplet
    4. A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?
      A)
      When walking, move your left foot forward first.
      B)
      Keep your elbow straight when you hold the cane.
      C)
      Move the cane forward 18 inches with each step.
      D)
      Hold the cane with your left hand.
    Page 3 of 24

    Exam Review

    1. A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia?
      A)
      Decreased heart rate
      B)
      Increased blood pressure
      C)
      Weak pulse
      D)
      Dyspnea
    2. A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown?
      A)
      A young adult who has a femur fracture and is in skeletal balanced suspension traction
      B)
      An older adult who has a hip fracture and is in Buck's traction
      C)
      An adolescent who has a cervical fracture and is in a halo brace
      D)
      A middle adult who has a fractured radius and an arm cast
    3. 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)
      Provide the client a sip of warm water, wait 5 minutes, and measure the temperature
      B)
      Document that the nurse was unable to measure the client's temperature
      C)
      Proceed to measure the oral temperature
      D)
      Wait 30 minutes and return to measure the oral temperature
    4. A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?
      A)
      To identify delayed gastric emptying
      B)
      To remove gastric acid that might cause dyspepsia
      C)
      To determine the client's electrolyte balance
      D)
      To confirm the placement of the NG tube
    Page 4 of 24

    Exam Review

    1. A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?
      A)
      Secure the restraints to the lowest bar of the side rail
      B)
      Secure the restraints using a quick-release tie
      C)
      Ensure four fingers fit under the restraints to prevent constriction
      D)
      Anticipate removing the restraints every 4 hours
    2. A nurse is removing personal protective equipment (PPE) after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove first?
      A)
      Gown
      B)
      Face shield
      C)
      Mask
      D)
      Gloves
    3. A nurse is admitting a client who has a wound infected with vancomycin-resistant enterococci (VRE). Which of the following types of precautions should the nurse plan to initiate?
      A)
      Airborne
      B)
      Protective
      C)
      Contact
      D)
      Droplet
    4. A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?
      A)
      Maintain the head of the bed in a flat position for 30 minutes following medication administration
      B)
      Mix the three medications together prior to administering
      C)
      Dilute each medication with 10 ml of tap water
      D)
      Flush the NG feeding tube with 30 ml of water immediately following medication administration
    Page 5 of 24

    Exam Review

    1. A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hours. Which of the following actions should the nurse take as directed by the plan of care?
      A)
      Instruct the client to tighten muscle groups for a short period, and then relax
      B)
      Move the client's limbs through their complete range of motion
      C)
      Ask the client to move her arms and legs while applying slight resistance
      D)
      Have the client move each limb independently through its complete range of motion
    2. A nurse is planning care for a group of clients. Which of the following clients should the nurse plan to utilize cold therapy?
      A)
      A client who has peripheral vascular disease
      B)
      A client who has a new ankle sprain
      C)
      A client who has a spinal cord injury
      D)
      A client who is unconscious
    3. A nurse is assisting an older adult client who sometimes loses her balance while walking. Which of the following devices should the nurse use when helping the client ambulate?
      A)
      Gait belt
      B)
      Jacket harness
      C)
      Cane
      D)
      Four-wheel walker
    4. A client receives an oral pain medication. In 1 hour the nurse should:
      A)
      Complete a report
      B)
      Call the client's provider
      C)
      Reassess the client
      D)
      Notify the nurse manager
    Page 6 of 24