Exam Review

A nurse is planning teaching about meditation for a client who reports feeling anxious. Which of the following statements should the nurse include in the teaching?
A)
Choose a word to help focus your attention.
B)
Quickly inhale deeply and hold your breath for 30 seconds.
C)
Plan for 1 hour of meditation for each session.
D)
Picture yourself in one of your favorite places.
A client presents to the unit after undergoing a bronchoscopy for a lung mass biopsy. At 1245, the client reports an acute onset of right-sided chest pain and progressively worsening shortness of breath with a pain scale of 8 out of 10. The client is diaphoretic and agitated with oral mucosa cyanotic and tracheal deviation noted. Chest expansion and breath sounds are diminished on the right side with intercostal retractions. A chest tube is placed and connected to a collection system. In which position should the nurse place the client to facilitate chest tube drainage and lung expansion?
A)
Lateral.
B)
Semi-Fowler's.
C)
Reverse Trendelenburg.
D)
Trendelenburg.
E)
High-Fowler's.
A nurse is completing an admission assessment for a client who has hearing loss. Which of the following actions should the nurse take?
A)
Limit the use of hand gestures when communicating with the client.
B)
Speak to the client with an increased pitch.
C)
Use written materials to assist with communication.
D)
Limit visitors to avoid communication misunderstandings.
A nurse is preparing to perform a routine abdominal assessment for a client. Which of the following actions should the nurse take?
(SATA)
A)
Document shiny, taut skin as an expected finding.
B)
Perform palpation after auscultation.
C)
Listen for 5 minutes before documenting absent bowel sounds.
D)
Perform auscultation immediately after the client has consumed a meal.

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Exam Review

A nurse is providing teaching about measures to promote sleep with a client who has insomnia. Which of the following client statements indicates an understanding of the teaching?
A)
I can exercise as late as 1 hour before bedtime.
B)
I should reduce my fluid intake 2 hours before bedtime.
C)
I should take a 1 hour nap each day.
D)
I can eat a large meal as late as 1 hour before bedtime.
A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the teaching?
A)
I need to have an attorney sign my advance directives.
B)
I have a living will that outlines my wishes if I am unable to make decisions.
C)
I must have a family member appointed to make my health care decisions.
D)
I will need to sign a document stating that I want to be resuscitated if I require CPR.
A nurse is assessing the IV infusion site of a client who reports pain. The site is swollen and there is warmth along the course of the vein. Which of the following actions should the nurse take?
A)
Initiate a new IV line below the original insertion site.
B)
Discontinue the infusion.
C)
Raise the head of the bed.
D)
Obtain a culture from the area of the insertion site.
A nurse is documenting client care. Which of the following entries should the nurse identify as an example of implementation of client care?
A)
Contacted the provider to report client findings.
B)
Reports stomach pain as 3 on a pain scale of 0 to 10.
C)
Vomited 120 mL of clear, yellow emesis.
D)
Denies further nausea or vomiting since antiemetic administration.

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Exam Review

A nurse is preparing to obtain the oxygen saturation of a client who has peripheral edema and thickened toenails. Which of the following actions should the nurse take?
A)
Attach a probe carefully to the client's finger to prevent discomfort.
B)
Apply a sensor pad to the client's forehead.
C)
Secure a probe to one of the client's toes.
D)
Obtain a pulse oximetry reading when peripheral edema has decreased.
A nurse is assessing a client who is receiving oxygen therapy. Which of the following findings should the nurse identify as a late manifestation of hypoxia?
A)
Bradypnea.
B)
Restlessness.
C)
Hypertension.
D)
Tachycardia.
A nurse is assisting a client who signed an informed consent form for surgery but has since expressed doubts about the need for surgery. Which of the following statements should the nurse make?
A)
The procedure cannot be cancelled once the consent is signed.
B)
It is in your best interest to have this surgery now.
C)
The surgeon will answer your Questions before surgery.
D)
Let me explain the surgery to you.
A nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. Which of the following actions should the nurse take to prevent contamination during the dressing change?
A)
Remove a piece of the new dressing that falls 5 cm (2 in) from the edge of the sterile field during the dressing change.
B)
Begin the dressing change by applying sterile gloves and removing the existing dressing.
C)
Restart the procedure if the sterile solution splashes onto the sterile field when pouring the solution into the dressing tray.
D)
Place the existing dressing on the outermost portion of the sterile field and discard it when the dressing change is finished.

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Exam Review

A nurse finds a client on the floor of their room experiencing a seizure. Which of the following actions is the nurse's priority?
A)
Place the client on their side with their head forward.
B)
Administer an anticonvulsant medication.
C)
Time the length of the client's seizure.
D)
Loosen the client's gown and allow them to move freely.
A nurse is caring for a client who has a nonpalpable skin lesion that is less than 0.5 cm (0.2 in) in diameter. Which of the following terms should the nurse use to document this finding?
A)
Papule.
B)
Vesicle.
C)
Nodule.
D)
Macule.
A nurse is planning a community education program about colorectal cancer. Which of the following risk factors should the nurse identify as modifiable?
A)
Smoking.
B)
Alcohol consumption.
C)
Inflammatory bowel disease.
D)
High-fat diet.
E)
Colorectal polyps.
A nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. The nurse should instruct the client to avoid which of the following foods?
A)
Orange slices.
B)
Ground hamburger.
C)
Cooked green beans.
D)
Canned peaches.

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Exam Review

A nurse in a provider's office is assessing the motor skill development of a 15-month-old toddler during a well-child visit. Which of the following gross motor skills should the nurse expect?
A)
Takes several steps on tip toes.
B)
Walks without assistance using a wide stance.
C)
Has an accentuated cervical curvature when standing.
D)
Stands with the feet turned slightly inward.
A nurse is teaching a group of assistive personnel about the expected integumentary changes in older adult clients. Which of the following findings should the nurse include in the teaching?
A)
Increase in subcutaneous tissue.
B)
Decrease in pigmentation.
C)
Increase in moisture levels.
D)
Decrease in elasticity.
A nurse is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. Which of the following findings should the nurse expect?
A)
Pulse oximetry reading of 95%.
B)
Decreased depth of respirations.
C)
Flaring of the nostrils.
D)
Respiratory rate of 16/min.
A nurse is caring for a client who has dementia and frequently tries to get out of bed. Which of the following actions should the nurse take?
A)
Turn on the bed alarm.
B)
Maintain the bed in the lowest position.
C)
Place the client in a vest restraint.
D)
Administer a sedative.
E)
Encourage the family to stay with the client.

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Exam Review

A nurse is preparing to transfer a client from a chair to the client's bed. The client can bear partial weight and has upper body strength. Which of the following devices should the nurse use to transfer the client?
A)
A stand-assist lift.
B)
A footboard.
C)
A slide board.
D)
A mechanical lift with a full body sling.
A nurse is performing a focused assessment for a client who has a dysrhythmia. Which of the following findings indicates ineffective cardiac contractions?
A)
Carotid bruit.
B)
Heart murmur.
C)
Pulse deficit.
D)
Bounding radial pulse.
A nurse is planning to administer several medications to a client through a nasogastric (NG) tube. Which of the following actions should the nurse take?
A)
Mix the medications together and administer through the NG tube.
B)
Crush the sublingual medication into powder form.
C)
Dissolve crushed tablet medications in sterile water.
D)
Flush the tube with 5 mL saline between each medication.
A nurse is caring for a client who expresses feeling overwhelmed that their partner has alcohol use disorder and has been unable to keep a job for longer than 3 months. Which of the following is an appropriate response by the nurse?
A)
"I'm sure your situation will get better with time.”.
B)
"It must be terrible to be in this situation.”.
C)
"If I were you, I would talk with the hospital chaplain.”.
D)
"Tell me what you've done in the past to cope with your problems.”.

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