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    Exam Review

    1. A nurse is assisting in the care of a client who has pneumonia. 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)
      Store the oxygen cylinder wrench with the oxygen tank.
      B)
      Take steroid medication in the morning.
      C)
      Decrease the steroid dose each day.
      D)
      Take antibiotic medication with or without food.
      E)
      Adjust the oxygen flow rate as needed to ease breathing.
      F)
      Ensure the oxygen delivery system
      G)
      Take antibiotics for 10 days.
    2. A home health nurse is assisting in the care of a client. Select the 4 findings that indicate an understanding of the reinforced teaching.
      (SATA)
      A)
      Amount of time washing hands
      B)
      Time leftovers sit unrefrigerated on countertop
      C)
      Refrigerator temperature
      D)
      Defrosting of frozen foods
      E)
      Leftover storage time in refrigerator
      F)
      Use of cutting board
    3. A nurse in a rehabilitation facility is assisting in the care of a client who was admitted the previous day. Complete the following sentence by using the list of options. The client is at risk for ▾ Aspiration   as evidenced by the client's ▾ Dysphagia
      Dropdown 1:
      Option 1: Sepsis
      Option 2: Tachycardia
      Option 3: Aspiration
      Dropdown 2:
      Option 1: Oxygenation
      Option 2: Prescribed medications
      Option 3: Dysphagia
    4. A nurse is assisting in the care of a client in a provider's office. A nurse is caring for the client. Which of the following prescriptions should the nurse anticipate the provider to prescribe? Select all that apply.
      (SATA)
      A)
      Administer an antibiotic.
      B)
      Keep daily fat intake to less than 35%.
      C)
      Limit alcohol intake to 2 drinks per day.
      D)
      Limit foods high in potassium.
      E)
      Administer a diuretic.
      F)
      Place on 2,300 mg sodium diet.
    Page 1 of 17

    Exam Review

    1. A nurse is assisting in the care of a client who is scheduled for an appendectomy. The nurse is assisting with preparing the client for surgery. Select the 3 findings that require follow-up prior to surgery.
      (SATA)
      A)
      Allergies
      B)
      Oxygen saturation
      C)
      Pain level
      D)
      Dietary intake
      E)
      Informed consent
      F)
      Blood pressure
    2. A nurse is assisting with the care of a client in a medical-surgical unit. Select words from the choices below to fill in each blank in the following sentence. The client is most at risk of developing   ▾ atelectasis  and ▾ paralytic ileus.
      Dropdown 1:
      Option 1: atelectasis
      Option 2: urinary tract infection
      Option 3: delayed wound healing
      Option 4: deep vein thrombosis
      Dropdown 2:
      Option 1: paralytic ileus
      Option 2: urinary tract infection
      Option 3: delayed wound healing
      Option 4: deep vein thrombosis
    3. A nurse is assisting in the care of a client. Complete the following sentence by using the lists of options. At 1000 the nurse enters the client's room. The first action the nurse should take is ▾ call for assistance followed by ▾ turn the client to their side.
      Dropdown 1:
      Option 1: remove the pillows
      Option 2: call for assistance
      Option 3: document the seizure event
      Dropdown 2:
      Option 1: reorient the client
      Option 2: administer anticonvulsant medications
      Option 3: turn the client to their side
    4. A nurse in a provider's office is reviewing the medical record of a client who reports having nausea and vomiting for the last 48 hr. Which of the following findings indicate fluid volume deficit? (Select all that apply.)
      (SATA)
      A)
      Decreased skin turgor
      B)
      Dry mucous membranes
      C)
      Distended neck veins
      D)
      Blood pressure 88/62 mm Hg
      E)
      Heart rate 72/min
    Page 2 of 17

    Exam Review

    1. A nurse is assisting with the care of a client who has cancer that has metastasized. The client has decided to discontinue chemotherapy treatment. Which of the following responses should the nurse make?
      A)
      "Don't worry. Everything will work out for you."
      B)
      "We should talk about your decision later."
      C)
      "How will you discuss this decision with your loved ones?"
      D)
      "Your quality of life will be compromised if you make this decision."
    2. A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply.)
      (SATA)
      A)
      Elevate the client's hand above the level of the heart.
      B)
      Squeeze the client's finger until a blood drop forms.
      C)
      Prick the side of the client's finger.
      D)
      Apply clean gloves.
      E)
      Cleanse the client's finger with an iodine swab.
    3. A nurse is assisting with the care of a client who had an indwelling urinary catheter inserted 3 days ago. Which of the following actions should the nurse take?
      A)
      Change the catheter bag every 3 days and as needed.
      B)
      Obtain urine from the drainage bag if a urinary specimen is required.
      C)
      Use a catheter securing device to hold the catheter in place.
      D)
      Position the drainage bag higher than the client's bladder.
    4. A nurse is disinfecting the room of a client who has a Clostridium difficile infection. Which of the following solutions should the nurse use?
      A)
      Isopropyl alcohol
      B)
      Chlorine bleach
      C)
      Chlorhexidine
      D)
      Triclosan
    Page 3 of 17

    Exam Review

    1. A nurse is assisting a client who is 4 hr postoperative with getting out of bed. The client states, "Do not touch me! I can get up by myself." Which of the following responses should the nurse make?
      A)
      "Why don't you want to be touched?"
      B)
      "Would you like some pain medication before getting out of bed?"
      C)
      "I will stand next to you and help if you need me to."
      D)
      "We can talk about this after you have gotten out of bed."
    2. A nurse is applying cold therapy to a client's face following oral surgery. The nurse should identify that which of the following is a therapeutic effect of cold therapy?
      A)
      Decreased edema formation
      B)
      Increased tissue metabolism
      C)
      Improved blood flow
      D)
      Reduced blood coagulation
    3. A nurse is preparing to insert a client's NG tube for enteral feedings. Which of the following actions should the nurse take first?
      A)
      Mark the length to be inserted on the tube with tape.
      B)
      Place a water-based lubricant on the tip of the tube.
      C)
      Compare the patency of the client's nares.
      D)
      Instruct the client to hyperextend her neck.
    4. A nurse is preparing to collect a stool specimen from a client for laboratory testing. Which of the following actions should the nurse take when collecting the specimen?
      A)
      Transfer the specimen to a cup without it touching the outside of the container.
      B)
      Wait for 4 hr before sending the specimen to the laboratory.
      C)
      Collect at least 7.62 cm (3 in) of the client's stool.
      D)
      Avoid collecting the specimen from areas of the stool that contain blood.
    Page 4 of 17

    Exam Review

    1. A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SaO2 level is 88% while on room air. Which of the following actions should the nurse take first?
      A)
      Notify the charge nurse of the client's condition.
      B)
      Review the client's most recent SaO2 level in the medical record.
      C)
      Check the client's medical records to see which medications were recently administered.
      D)
      Recheck the client's SaO2 level after having the client cough and clear their throat.
    2. A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse take?
      A)
      Speak loudly and clearly
      B)
      Face the client when speaking
      C)
      Use a high-pitched tone
      D)
      Rephrase sentences frequently
    3. A nurse at a provider's office is collecting physical data from an older adult client. Which of the following images should the nurse identify as an example of an expected age-related change?
    4. A nurse is caring for a client who has terminal cancer. The client tells the nurse, "I feel worn out and don't have the energy to fight this disease. Am I dying?" Which of the following responses should the nurse make?
      A)
      "You are concerned that you are dying?"
      B)
      "It is normal to feel this way with your type of cancer."
      C)
      "Why do you think you are dying?"
      D)
      "I think you should have some quiet time to get some rest."
    Page 5 of 17

    Exam Review

    1. A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about incident reporting. The nurse should identify that it is necessary to complete an incident report for which of the following situations?
      A)
      A client's bed alarm is malfunctioning.
      B)
      A family member is napping in the client's room.
      C)
      An assistive personnel is late for the upcoming shift.
      D)
      A client refuses to eat at mealtime.
    2. A nurse is preparing to reinforce teaching with a client who has expressive aphasia. Which of the following actions should the nurse plan to take?
      A)
      Provide the teaching without expecting the client to respond.
      B)
      Determine the client's ability to use a communication board
      C)
      Speak with a loud voice while providing the information.
      D)
      Avoid the use of facial gestures during the instructions.
    3. 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.
    4. A nurse is observing an assistive personnel (AP) who is performing hand hygiene. The nurse should recognize that the AP is using proper technique when he does which of the following?
      A)
      Uses firm, circular motions to wash his hands
      B)
      Washes his hands under hot running water
      C)
      Scrubs hands with antibacterial soap for 10 seconds
      D)
      Dries his hands from the forearms to the fingers
    Page 6 of 17