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    Exam Review

    1. A nurse is caring for a client in the emergency department (ED). Exhibits 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.
      ✓Obtain prescription for naloxone
      ✓Prepare to initiate mechanical ventilation
      ✓Opioid Intoxication
      ✓Pupillary reaction
      ✓Respiratory rate
      Actions to Take Choices
      ✕Obtain prescription for restraints
      ✕Anticipate administering clonidine
      ✓Obtain prescription for naloxone
      ✓Prepare to initiate mechanical ventilation
      Potential Condition Choices
      ✕Stimulant intoxication
      ✕Opioid withdrawal
      ✓Opioid Intoxication
      ✕Alcohol intoxication
      Parameters to Monitor Choices
      ✕Cardiac arrhythmias
      ✓Pupillary reaction
      ✕Ethanol level
      ✓Respiratory rate
    2. A nurse is caring for a 9-year old child on the pediatric unit Exhibits Complete the following sentence by using the lists of options. The nurse should plan to ▾ inspect the child's oropharynx followed by ▾ Obtaining a set of vital signs.
      Dropdown 1:
      Option 1: inspect the child's oropharynx
      Option 2: offer the child a red popsicle
      Option 3: place the child in a supine position
      Dropdown 2:
      Option 1: Requesting a prescription for codeine
      Option 2: Encouraging the child to cough and deep breathe
      Option 3: Obtaining a set of vital signs
    3. A nurse is teaching about methods to promote sleep to a client who has insomnia. Which of the following statements should the nurse make?
      A)
      "Perform 20 minutes of cardiovascular exercise 1 hour before bedtime."
      B)
      "Avoid eating heavy meals 3 hours before bedtime."
      C)
      "If you are unable to sleep, wait 1 hour before trying a quiet activity."
      D)
      "Avoid caffeinated beverages 2 hours prior to bedtime."
    4. A nurse is performing a vaginal examination on a client who is in labor and palpates a prolapsed umbilical cord. After notifying the provider, which of the following actions should the nurse take?
      A)
      Initiate oxygen at 8 L/min via a nonrebreather mask.
      B)
      Attempt to replace the protruding cord through the cervical os.
      C)
      Exert upward pressure on the presenting part.
      D)
      Place the client in reverse Trendelenburg position.
    Page 1 of 22

    Exam Review

    1. A client who has uncontrollable urges to overeat gives a series of presentations in her workplace about nutrition guidelines for a healthy lifestyle. The nurse counseling this client should identify that the client is displaying which of the following defense mechanisms?
      A)
      Projection:
      B)
      Sublimation
      C)
      Introjection
      D)
      Dissociation
    2. A case manager is performing a home visit for a client following a stroke. The client's partner is providing care in the home. The client's partner states that she sometimes feels exhausted. Which of the following referrals should the case manager recommend for the caregiver?
      A)
      Skilled nursing facility
      B)
      Respite care
      C)
      Assisted living
      D)
      Rehabilitation services
    3. A nurse is planning to administer packed RBCs to an older adult client who has a low hemoglobin level. Which of the following actions should the nurse plan to take?
      A)
      Hang the transfusion with dextrose 5% in 0.9% sodium chloride.
      B)
      Infuse the transfusion over 5 hr.
      C)
      Use a 20 gauge IV catheter to transfuse the blood.
      D)
      Monitor vital signs every hour throughout the transfusion.
    4. A nurse is teaching a client who is postpartum about home safety for her newborn. Which of the following Instructions should the nurse include?
      A)
      Set the hot water heater to 52° C (125° F).
      B)
      Place the playpen near a heat vent during cold weather.
      C)
      Position the crib away from the cords of blinds and drapes.
      D)
      After feeding, place the newborn on his stomach.
    Page 2 of 22

    Exam Review

    1. A nurse is teaching a newly licensed nurse about maintaining confidentiality within the nurse-client relationship. The nurse should include that which of the following situations warrants reporting confidential information?
      A)
      When the client has a cognitive disorder
      B)
      When the client's hospitalization is involuntary
      C)
      When a member of the client's immediate family requests information
      D)
      When the client has communicated an intention to harm someone
    2. A nurse is caring for a client who is displaying combative behavior. Which of the following actions should the nurse take first?
      A)
      Place the client in restraints.
      B)
      Escort the client to a place of seclusion.
      C)
      Offer the client PRN medication,
      D)
      Offer the client choices for a diversionary activity.
    3. A nurse is caring for a client who is displaying combative behavior. Which of the following actions should the nurse take first?
      A)
      Place the client in restraints.
      B)
      Escort the client to a place of seclusion.
      C)
      Offer the client PRN medication,
      D)
      Offer the client choices for a diversionary activity.
    4. A home health nurse is planning care for an older adult client who has vision loss and takes medications throughout the day. Which of the following actions should the nurse include in the plan?
      A)
      Cover appliance cords with throw rugs.
      B)
      Rearrange furniture to clear walkways.
      C)
      Visit the client once per month to assess medication usage.
      D)
      Use container lids of different shapes to indicate times of administration.
    Page 3 of 22

    Exam Review

    1. A nurse in an inpatient mental health facility sees a client who is talking while walking alone. The client tells the nurse, "This guy in my head says I am to blame for my own illness." Which of the following responses should the nurse make?
      A)
      "It is not possible to have someone else in your head talking to you."
      B)
      "Why do you think he is telling you what to do?"
      C)
      "Although I can't hear that voice, it must be very upsetting for you."
      D)
      "Are you sure it wasn't your roommate telling you that?"
    2. A nurse is teaching a newly licensed nurse about contact precautions. The nurse should include that a client who has which of the following diseases requires contact precautions?
      A)
      Varicella
      B)
      Pertussis
      C)
      Clostridium difficile
      D)
      Mycobacterium tuberculosis
    3. A nurse is caring for a client 15 min following a bronchoscopy with moderate sedation. Which of the following actions should the nurse take first?
      A)
      Offer the client oral fluids.
      B)
      Check the client's IV site.
      C)
      Obtain the client's oxygen saturation level.
      D)
      Determine the client's level of consciousness.
    4. A nurse is planning care for a client who has chemotherapy-related immunosuppression. Which of the following interventions should the nurse add to the client's plan of care?
      A)
      Measure the client's rectal temperature daily.
      B)
      Encourage ambulation in the facility's hallways.
      C)
      Monitor the client's temperature every 8 hr.
      D)
      Monitor the client's WBC count daily.
    Page 4 of 22

    Exam Review

    1. A nurse is reviewing laboratory data for a client who has a new prescription for valproic acid. Which of the following baseline results should the nurse review prior to administering the first dose of the medication?
      A)
      Liver function tests
      B)
      Potassium level
      C)
      Uric acid level
      D)
      Thyroid function tests
    2. A nurse is preparing to obtain a blood specimen from a client's central venous access device. Prior to collecting the specimen, the nurse should clean the connection thoroughly with which of the following antiseptics?
      A)
      Povidone-iodine
      B)
      Hydrogen peroxide
      C)
      2% chlorhexidine
      D)
      70% alcohol solution
    3. A nurse is assisting in the selection of foods for a client who has dysphagia caused by a stroke. Which of the following foods should the nurse recommend?
      A)
      Crispy rice bar
      B)
      Soda crackers
      C)
      Peanut butter
      D)
      Scrambled eggs
    4. A case manager is making a referral to hospice for a client who has cancer and has decided to stop curative treatments. The case manager is upholding which of the following ethical principles?
      A)
      Autonomy
      B)
      Distributive justice
      C)
      Veracity
      D)
      Fidelity
    Page 5 of 22

    Exam Review

    1. A nurse is caring for a client who is on long-term therapy for peptic ulcer disease and has a new diagnosis of osteoporosis. The nurse should Identify that osteoporosis is an adverse effect of which of the following medications?
      A)
      Omeprazole
      B)
      Famotidine
      C)
      Bismuth
      D)
      Magnesium hydroxide
    2. A community health nurse is developing a budget for strategies that target the primary level of prevention. Which of the following interventions should the nurse include in the budget?
      A)
      Scheduling healthy cooking classes for clients who have hypertension
      B)
      Performing environmental assessments to identify local safety issues
      C)
      Hosting early detection programs for substance use at local high schools
      D)
      Implementing influenza immunization clinics for older adults
    3. A nurse is planning care for a group of clients. Which of the following situations requires the nurse to complete an incident report?
      A)
      An assistive personnel arrives for her shift with alcohol on her breath.
      B)
      A client's family member falls in the unit hallway.
      C)
      A client does not have advance directives in his medical record.
      D)
      A client refuses a blood transfusion.
    4. A nurse in the labor and delivery unit is preparing a safety plan for a group of newly licensed nurses. Which of the following individuals should the nurse identify as posing a risk for infant abduction?
      A)
      A client who delivered a full-term newborn who has suspected celiac disease
      B)
      A client who delivered a preterm newborn who has cardiac anomalies
      C)
      A client who recently experienced the loss a of pregnancy
      D)
      A client who is experiencing complications related to preeclampsia
    Page 6 of 22