Exam Review

A nurse is reinforcing teaching about end-of-life care with the partner of a client. Which of the following statements should the nurse make?
A)
"We will use an electric blanket to keep your partner warm."
B)
"Encourage your partner to eat three large meals each day."
C)
"Assume your partner can hear you, even if they do not respond."
D)
"Opioids will be restricted if your partner develops respiratory distress."
A nurse is assisting with the care of a client who has a recent diagnosis of a chronic condition and is exhibiting findings of ineffective coping. Which of the following actions should the nurse take first?
A)
Determine if the client has a support system.
B)
Schedule a mental health consult for the client.
C)
Provide the client with information about coping strategies.
D)
Encourage the client to attend a support group.
A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?
A)
Add 0.5 mL of diluent to the medication.
B)
Inject air into the ampule prior to drawing the medication into a syringe.
C)
Use a filter needle to aspirate the medication.
D)
Cleanse the tip of the ampule with an alcohol swab after opening.
A nurse is providing nonpharmacological interventions for a client who is experiencing pain. Which of the following actions should the nurse take
A)
Play music in the client's room.
B)
Keep the client's room well lit.
C)
Ensure that the client's room is kept at a cool temperature.
D)
Encourage the client to abstain from distracting activities.

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Exam Review

A nurse is collecting data from a client who has a stage 4 pressure injury. Which of the following supplies should the nurse obtain?
A)
Cotton-tipped applicator
B)
Tongue depressor
C)
Adhesive tape
D)
Syringe
A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
(SATA)
A)
Observe the client's skin integrity every 2 hr.
B)
Use a square knot to secure the client's restraint to the bed.
C)
Ensure that 2 fingers can be placed between the restraint and the client.
D)
Tie the ends of the restraint to the client's bed rail.
E)
Pad bony prominences before applying a restraint.
A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)
(SATA)
A)
A client reports being dissatisfied with the temperature of the meals provided.
B)
A client receives burns from a heating pad.
C)
A client becomes disoriented and falls out of bed.
D)
A client is unable to afford the physical therapy that the provider recommends.
E)
A client's visitor becomes dizzy and faints in the client's room.
A nurse is delegating client care to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
A)
Administering vaginal cream to a client who has a vaginal infection
B)
Providing postmortem care for a client who has just died
C)
Suctioning a tracheostomy for a client who has a recent head injury
D)
Changing a peripheral IV dressing for a client who is postoperative

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Exam Review

Exhibits The nurse is reinforcing discharge teaching with the client and their caregiver. Which of the following information should the nurse include? Select all that apply.
(SATA)
A)
Ensure the oxygen delivery system is at least 8 feet from any heat source
B)
Adjust the oxygen flow rate as needed to ease breathing.
C)
Take antibiotic medication with or without food.
D)
Decrease the steroid dose each day.
E)
Take antibiotics for 10 days.
F)
Store the oxygen cylinder wrench with the oxygen tank.
G)
Take steroid medication in the morning.
A charge nurse is observing a newly licensed nurse caring for a client group. Which of the following statements by the newly licensed nurse indicates an understanding of infection control principles?
A)
"I will rinse the contaminants from a bedpan with hot water."
B)
"I will wear sterile gloves when bathing a client who is incontinent."
C)
"I will use disinfectant to clean the blood pressure cuff after use on a client."
D)
"I will double-bag a client's linens each day."
A nurse is recording the intake and output (I&O) for a client. The client consumed 8 oz of milk, 10 oz of water, 4 oz of gelatin, 1 egg, 1 piece of bacon, and 2 biscuits. Which of the following volumes should the nurse record on the I&O?
A)
440 mL
B)
660 mL
C)
330 mL
D)
550 mL
A nurse is caring for a client who is receiving detoxification treatment for an opioid use disorder. As the nurse is preparing to administer a methadone IM injection, the client tells the nurse, "I am afraid of needles." Which of the following actions should the nurse take?
A)
Request a change in the medication route to PO.
B)
Remind the client that they must receive the medication as prescribed.
C)
Tell the client not to worry because the pain will be temporary.
D)
Ask one of the client's loved ones to encourage them to receive the IM

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Exam Review

13. A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
A)
Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
B)
Unlock and remove the inner cannula.
C)
Scrub the inside and outside of the inner cannula with a small brush.
D)
Cleanse the stoma site with 0.9% sodium chloride solution.
E)
Wipe the inside of the inner cannula with a folded pipe cleaner.
A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification and. Which of the following actions should the nurse take to verify the client's identity?
A)
Ask the client to state their room number.
B)
Have the client state their phone number.
C)
Review the client's photograph in the medical record.
D)
Request an assistive personnel to identify the client.
A nurse is reinforcing teaching about advance directives with a client who has terminal colorectal cancer. Which of the following statements by the client indicates an understanding of the teaching?
A)
"I'm glad to have the opportunity to choose what kind of care I receive while I still can."
B)
"If I want life support, I'll need to sign a separate consent form first."
C)
"I can't change my mind about the care I will receive once I sign my living will."
D)
"Once I fill out my living will, there will be a 1-month delay before it is legally binding."
A nurse is caring for a client who follows a lacto-vegetarian diet. Which of the following food choices should the nurse recommend?
A)
Tuna fish
B)
Clam chowder
C)
Cheese
D)
Chicken

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Exam Review

A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SpO2 level is 88% while on room air. Which of the following actions should the nurse take first?
A)
Recheck the client's SaO2 level after having the client cough and clear their throat.
B)
Notify the charge nurse of the client's condition.
C)
Review the client's most recent SaO2 level in the medical record.
D)
Check the client's medical records to see which medications were recently admitted.
A nurse is collecting a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?
A)
Place the specimen in a clean specimen cup.
B)
Clamp the catheter tubing below the needleless port.
C)
Clamp the catheter tubing for 60 min.
D)
Remove 45 mL of urine from the catheter with a syringe.
A nurse is preparing to insert an indwelling urinary catheter and is verifying the client's express consent for this procedure. Which of the following actions should the nurse take?
A)
Obtain verbal consent from the client.
B)
Witness the client's signature on a consent form.
C)
Check the medical record for the client's signature on a previous consent form.
D)
Have another nurse co-sign the client's consent
A nurse is reviewing the medical record of a client Exhibits Click to highlight below the findings that require immediate follow-up. Body System Findings Neurological Alert and oriented to person, place, and time; deep tendon reflexes 4+ Musculoskeletal Generalized weakness with equal bilateral muscle strength and mild leg cramping Respiratory : Lungs clear Cardiovascular : Heart rate irregular, Heart rate 95/min Gastrointestinal Bowel sounds hyperactive x 4 quadrants
A)
deep tendon reflexes 4+
B)
Heart rate irregular
C)
Bowel sounds hyperactive x 4 quadrants
D)
Generalized weakness with equal bilateral muscle strength and mild leg cramping
E)
Lungs clear
F)
Heart rate 95/min
G)
Alert and oriented to person, place, and time;

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Exam Review

A nurse is reinforcing teaching with a client about blood glucose monitoring. The client becomes quiet and appears distracted while the nurse is providing the instructions. Which of the following responses should the nurse make?
A)
"Aren't you interested in learning how to perform this test?"
B)
"Let's talk about what you're thinking."
C)
"I'll discuss this with your partner instead."
D)
"Is this something you think you can do?"
A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?
A)
The stoma bleeds lightly when touched.
B)
The stoma appears dark in color.
C)
The stoma protrudes slightly from the abdomen.
D)
The stoma is draining a small amount of liquid stool.
A nurse is transferring a client to another unit. Which of the following statements should the nurse include in the transfer report?
A)
"He appears anxious about the transfer."
B)
"He is voiding adequately."
C)
"He is allergic to sulfa."
D)
"His partner has been visiting."
A nurse is setting up a sterile field in a client's room. Which of the following actions should the nurse take?
A)
Placing a sterile instrument within 1.3 cm (0.5 in) of the edge of the sterile field
B)
Opening the top flap of the sterile tray package away from their body
C)
Dropping sterile objects onto the field from a height of 5 cm (2 in)
D)
Placing the cap of a sterile solution on a clean surface with the inside facing down

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