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    Exam Review

    1. A surgical nurse is participating in a time-out procedure for a client who has just arrived in the surgical suite. The nurse is aware that a time-out is completed to ensure which of the following?
      A)
      The client's insurance information is documented in the chart.
      B)
      Contact information for family members is noted in the record.
      C)
      The correct surgical site is marked.
      D)
      Admission laboratory studies are complete
    2. A nurse is caring for a client who has skeletal traction applied to the left leg. Which of the following actions should the nurse take?
      A)
      Remove the weights before changing the client's bedlinens
      B)
      Check pressure points every 12 hr.
      C)
      Instruct the client to use their elbows to reposition.
      D)
      Provide the client with a trapeze bar.
    3. A nurse is providing education about medication therapy to the family of an older adult client who has a diagnosis of Alzheimer's disease. Which of the following statements by the family indicates an understanding of the teaching?
      A)
      "Current medications are meant to help slow down the progressive decline."
      B)
      "Miracle cures are on the horizon to treat this debilitating disease."
      C)
      "Cholinesterase inhibitors are safe and have very few side effects."
      D)
      "Benzodiazepines are the best option to help treat their behavior disturbances."
    4. A nurse is planning care for a client who has peripheral arterial disease. Which of the following interventions should the nurse include in the plan?
      A)
      Place the client's feet below the level of the heart.
      B)
      Apply knee-high stockings to the client's lower extremities.
      C)
      Apply a heating pad to the client's feet for comfort.
      D)
      Scrub the client's lower extremities vigorously when washing.
    Page 1 of 25

    Exam Review

    1. A nurse is caring for a client in an outpatient clinic. For each provider prescription, click to specify if the order is indicated or not indicated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.
      IndicatedNot indicated
      Spironolactone 50 mg PO once dally✓
      Obtain BUN and creatinine✓
      Albuterol dry powder inhaler, inhale 2 puffs every 4 to 6 hr PRN shortness of breath✓
      Fluid restriction of 0.5 L per day✓
      Enalapril 2.5 mg PO twice daily✓
      Potassium 20 mEq PO twice daily✓
    2. A nurse is assessing a client who has type 1 diabetes mellitus.
      (Highlight — findings requiring follow-up are marked)

      A nurse is assessing a client who has type 1 diabetes mellitus.

      Click to highlight the findings below that require immediate follow-up. To deselect a finding, click on the finding again.

       

      Body System

      Findings

      Cardiovascular

      Pulse is rapid. Heart rate. S1 and S2 on auscultation. Peripheral pulses palpable. Capillary refill less than 2 seconds.

      Blood pressure

      Respiratory

      Respirations deep and rapid. Fruity odor noted to breath. Rhonchi to right lung on auscultation, frequent nonproductive cough noted.

      Respiratory rate

      ABGS

      Genitourinary

      Client reports frequent urination with no difficulty.

      Urine ketones

      BUN level
    3. A nurse is planning care for a client who is taking hydrochlorothiazide for hypertension. The nurse should plan to monitor and report which of the following findings as an adverse effect of this medication?
      A)
      Urinary retention
      B)
      Hypoglycemia
      C)
      Peripheral edema
      D)
      Muscle weakness
    4. A nurse is preparing to directly admit a client from the provider's office and is reviewing their electronic medical record. When assessing the client, which of the following findings should the nurse expect? Select all that apply.
      (SATA)
      A)
      Muscle weakness
      B)
      Client report of tingling sensations in their hands
      C)
      Elevated temperature
      D)
      Bladder distension
      E)
      Client report of recent loose stools
      F)
      Client report of double vision
    Page 2 of 25

    Exam Review

    1. A nurse is planning care for a client who is experiencing seizures secondary to meningitis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)
      (SATA)
      A)
      Place a tongue blade at the bedside.
      B)
      Dim the overhead lights.
      C)
      Assist the client to ambulate every 4 hr.
      D)
      Apply a warming blanket.
      E)
      Have suction equipment at the bedside
    2. A nurse is preparing to discharge a client who has a long-term central venous access device. Which of the following statements should the nurse make?
      A)
      "Change the dressing using clean technique."
      B)
      "Refrain from wearing any type of artificial nails."
      C)
      "Do not take showers, take baths only."
      D)
      "Return to the provider to have the line flushed."
    3. A nurse is caring for a client who has partial hearing loss. Which of the following interventions should the nurse take when communicating with the client?
      A)
      Dim the lights in the room before speaking to the client.
      B)
      Stand directly in front of the client before speaking.
      C)
      Speak loudly when communicating with the client.
      D)
      Use hand motions near the mouth when speaking to the client.
    4. A nurse in the emergency department (ED) is caring for a client. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
    Page 3 of 25

    Exam Review

    1. A nurse is caring for a client who is receiving vancomycin IV. Which of the following findings should the nurse document as an adverse reaction to this medication?
      A)
      Reddish-orange colored urine
      B)
      Dizziness when sitting up in bed
      C)
      Increased systolic blood pressure
      D)
      Rash over the face and neck
    2. A nurse on a medical-surgical unit is caring for a client who has COPD. For each nursing action, click to specify if the nursing action is indicated or not indicated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.
      A)
      Provide four to six small meals per day.
      B)
      Allow for adequate rest periods.
      C)
      Encourage participation in community activities.
      D)
      Administer supplemental oxygen to maintain oxygen saturation at 98% to 100%
      E)
      Maintain client in supine position.
      F)
      Educate on smoking cessation.
    3. A nurse is reviewing a client's ECG rhythm strip. Which of the following components should the nurse use to measure impulse conduction from the sinus node through the atrioventricular node?
      A)
      PP interval
      B)
      ST segment
      C)
      QRS complex
      D)
      PR interval
    4. Patient Data Complete the diagram by dragging from the choices below to specify the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
    Page 4 of 25

    Exam Review

    1. A nurse is preparing a teaching plan for a client who has mucositis related to chemotherapy treatment. Which of the following instructions should the nurse include?
      A)
      "Floss your teeth gently following each meal."
      B)
      "Brush your teeth for 60 seconds twice daily."
      C)
      "Rinse your mouth with hydrogen peroxide."
      D)
      "Wear your dentures only during meals."
    2. A nurse in an emergency department is caring for a client who is confused and has a temperature of 40.1° C (104.2° F). Which of the following actions should the nurse take?
      A)
      Administer cooled 0.9% sodium chloride solution.
      B)
      Check the client's temporal temperature every 15 min.
      C)
      Give an acetaminophen suppository.
      D)
      Start an infusion of pancuronium.
    3. A nurse is completing a focused assessment on a client who has viral hepatitis. Which of the following findings should the nurse expect?
      A)
      Decrease in alkaline phosphatase level
      B)
      Melena stools
      C)
      Decrease in white blood cells
      D)
      Dark brown urine
    4. A nurse is caring for a client who has been administered a prescribed opioid analgesic following a thoracotomy. Which of the following assessment findings should the nurse document as a therapeutic effect of the medication?
      A)
      Pain "tolerable" at a 3 on a scale of 0 to 10
      B)
      Alert and oriented x3
      C)
      Lung sounds clear bilaterally
      D)
      Bowel sounds present and active x4
    Page 5 of 25

    Exam Review

    1. A nurse is caring for a client with end-stage breast cancer who is experiencing depression. Which of the following complementary therapies should the nurse incorporate into the care plan to assist with this manifestation?
      A)
      Shiatsu
      B)
      Journaling
      C)
      Acupuncture
      D)
      Reiki
    2. A nurse is caring for a client who is 24 hr postoperative following the placement of an external fixator to the left lower leg. Which of the following assessment findings requires immediate intervention by the nurse?
      A)
      The client is reporting muscle spasms in the left leg.
      B)
      The pin sites are reddened.
      C)
      The client is reporting decreased sensation in the left foot.
      D)
      The pin sites have clear drainage.
    3. A nurse is creating a plan of care for a client who has a newly implanted transcutaneous pacemaker. Which of the following interventions should the nurse include in the plan?
      A)
      Place a pressure dressing over the incision site.
      B)
      Administer an analgesic to the client.
      C)
      Instruct the client to restrict arm movement for 1 week.
      D)
      Apply antibiotic ointment to the skin around the site.
    4. A nurse is planning care for a client who has a chest drainage system set to low suction following a thoracotomy. Which of the following actions should the nurse include in the plan of care?
      A)
      Empty the collection chamber every 8 hr.
      B)
      Keep the water seal chamber at chest level.
      C)
      Loop excess tubing below the chest wall.
      D)
      Check for bubbling in the water seal chamber.
    Page 6 of 25