Exam Review

The practical nurse (PN) is providing instructions to the unlicensed assistive personnel (UAP) preparing to give a total bed bath to an immobile client who has a continuous feeding via gastrostomy tube (GT). Which instruction is most important for the PN to emphasize?
A)
Raise the entire bed while bathing the client to reduce back strain
B)
Report any drainage observed around the GT insertion site
C)
Keep the head of the bed raised while the tube feeding is infusing
D)
Use plenty of pillows to position the client on the side after bathing.
Prior to administering pain medication to an adult postoperative client, what information should the practical nurse (PN) obtain? (Select all that apply.)
(SATA)
A)
Height and weight of client prior to admission
B)
Client's pain rating on a scale of 1 to 10
C)
Time of last administration of pain medication
D)
Eﬀectiveness of last pain medication administered
E)
History of pain medication use during the past year
A nurse is reinforcing teaching with the parents of an infant who has a Pavlik harness. Which of the following statements should the nurse include in the teaching?
A)
"You should place the diaper over the strap of the harness.”
B)
"The harness can be removed for sleeping each night.”
C)
"You can apply lotion under the straps of the harness.”
D)
"The harness can promote hip joint development.”
A nurse is reviewing laboratory findings for three clients.Which of the following laboratory results should the nurse expect for a client who has cirrhosis?
A)
Elevated amylase.
B)
Decreased bilirubin.
C)
Elevated lipase.
D)
Elevated ammonia.

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Exam Review

A nurse is assisting with discharge planning for a client who is prescribed home oxygen at 1 to 2 L/min.The nurse should ensure that the client has which of the following supplies upon discharge?
A)
Oxygen mask.
B)
Reservoir bag.
C)
Petroleum jelly.
D)
Nasal cannula.
A nurse is preparing a client's body for a postmortem family viewing. Which of the following actions should the nurse take?
A)
Remove the client's dentures to close their mouth.
B)
Place medical equipment to the side of the client's bed.
C)
Lie on the head of the client's bed flat.
D)
Ask the family if they want to participate in postmortem care.
A nurse is participating in an interprofessional team meeting for a client.Which of the following information about the client should the nurse include?
A)
The client has developed difficulty ambulating.
B)
The client's next dressing change is scheduled in 4 hr.
C)
The client has state-sponsored health insurance.
D)
The client's vital signs are checked every 8 hr.
A nurse is reinforcing teaching with a client who is at 36 weeks of gestation and is about to undergo an amniocentesis.Which of the following information should the nurse include in the instructions?
A)
"I will need to give you Rh(D) immune globulin because you are Rh positive.”
B)
"You will need to have an empty bladder for the test.”
C)
"You will have to lie on your left side during the test.”
D)
"You will have to drink 50 grams of oral glucose before the test.”

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Exam Review

A nurse is reviewing the plan of care for a group of clients.The nurse should identify that informed consent is required for which of the following procedures?
A)
Placement of a central venous catheter.
B)
Insertion of a nasogastric tube.
C)
Irrigation of a wound with antibiotic solution.
D)
Administration of an iron injection using Z-track technique.
A nurse in a provider's office is reinforcing teaching about skin care with a client who has a new diagnosis of systemic lupus erythematosus.Which of the following statements by the client indicates an understanding of the teaching?
A)
"I will cleanse my skin using an antibacterial soap.”
B)
"I will dry my skin by patting it with a towel.”
C)
"I will use an astringent on my face.”
D)
"I will limit my time in the tanning bed to 15 minutes.”
A nurse is providing care to a client who is immunocompromised. Which of the following should the nurse identify as a possible source of infection?
A)
Waste containers are lined with single bags.
B)
Dampened cloths are used for dusting the area.
C)
Uncapped sharps are put in a puncture-resistant container
D)
Soiled linens are placed on the floor.
A nurse is caring for a client who has depressive disorder.The client states, "Everyone would be better off if I were not around." Which of the following responses should the nurse make?
A)
When you get better you will not feel this way.
B)
Why would you think a thing like that?
C)
What would your family do without you?
D)
Are you thinking of hurting yourself?

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Exam Review

A nurse in an acute care setting is preparing to administer medications to a client. Which of the following information should the nurse obtain to identify the client?
A)
Name of the client
B)
Client's telephone number
C)
Room number of the client
D)
Client's full medical diagnosis
A nurse is caring for a client who is cyanotic and has a respiratory rate of 8/min with shallow respirations.Which of the following is the priority action by the nurse?
A)
Place a pulse oximeter on the client's finger.
B)
Establish a patent airway for the client.
C)
Check the client's pulse rate.
D)
Administer oxygen to the client.
A nurse is collecting data from a client who is 2 days postpartum.The client tells the nurse she cannot afford to pay for baby formula.The nurse should refer the client to which of the following members of the interprofessional team?
A)
Nutritionist
B)
Case manager
C)
Primary care provider
D)
Pediatric nurse practitioner
A nurse is caring for a client who has paranoid schizophrenia and believes that they are being followed by FBI agents who are pretending to be psychiatric staff.Which of the following responses should the nurse make?
A)
"This must be very frightening for you. Let's talk more about it."
B)
"The psychiatric staff is not FBI. They are here to help you."
C)
"What makes you think the staff is following you?"
D)
"Why do you feel the staff is the FBI?"

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Exam Review

A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy.The nurse should explain to the client that which of the following adverse reactions can occur following the procedure?
A)
Neck pain
B)
Temporary memory loss
C)
Voice alteration
D)
Tingling of the scalp
A nurse is caring for a client who has a prescription for levothyroxine.Which of the following laboratory tests should the nurse monitor?
A)
Triiodothyronine.
B)
Prothrombin time.
C)
Blood urea nitrogen.
D)
Serum potassium.
A nurse is providing a client with IV fluids and finds that the IV pump screen is malfunctioning.Which of the following actions should the nurse take?
A)
Discontinue use and tag the IV pump.
B)
Plug the IV pump's cord into a different outlet.
C)
Replace the IV pump's tubing
D)
Clear the settings and reset the IV pump.
A nurse is assisting with a community health education program about childhood communicable diseases.Which of the following information should the nurse include in the presentation?
A)
Children who have erythema infectious (fifth disease) require short-term antibiotic therapy.
B)
Isolate children who have varicella until the vesicles have formed crusts.
C)
Administration of childhood immunizations will prevent exanthem subitem (roseola infantum).
D)
Restrict fluids for children who have pertussis.

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Exam Review

A nurse is collecting data from a client who has placenta previa.Which of the following findings should the nurse expect?
A)
Increased fetal movement
B)
Persistent uterine contractions
C)
Rigid abdomen
D)
Bright red vaginal bleeding
A nurse is reviewing client confidentiality with other staff members. The nurse should identify that which of the following actions is an example of protecting client confidentiality?
A)
Giving change-of-shift report to a nurse outside the client's room
B)
Discussing a client's prognosis with an assistive personnel who is caring for the client
C)
Writing a client's diagnosis on the message board in the client's room
D)
Discarding worksheets containing client information in a wastebasket
A charge nurse in a long-term care facility notices the smell of alcohol on a nurse's breath.Which of the following actions should the nurse take first?
A)
Assign clients to the remaining staff.
B)
Call the supervisor to ask for another nurse.
C)
Remove the nurse from the client care area.
D)
Document objective findings about the situation.
A nurse working on a medical-surgical unit is notified about a mass casualty event that recently took place in the community. Which of the following assignments should the nurse anticipate?
A)
Assist in discharging stable clients to home.
B)
Determine the acuity and number of casualties arriving at the facility.
C)
Delegate tasks to emergency health care specialists.
D)
Provide informational updates to members of the media.
E)
None
F)
None

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