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    Exam Review

    1. A nurse is preparing to care for clients following change-of-shift report. Which of the following clients should the nurse assess first?
      A)
      A client who has a wound infection and a temperature of 38.9° C (102° F)
      B)
      A client who is preoperative and needs to sign the consent form
      C)
      A client who has received opioids and reports constipation
      D)
      A client who is postoperative and has a BP of 88/48 mm Hg
    2. A nurse is preparing to take the pulse of an infant. Which of the following is the best site to perform this check on an infant?
      A)
      Apical
      B)
      Radial
      C)
      Femoral
      D)
      Ulnar
    3. A nurse in a well-child clinic receives a telephone call from a parent who states that their child accidentally swallowed paint thinner. The child is awake and alert. Which of the following responses should the nurse make?
      A)
      "Induce vomiting in your child with syrup of ipecac."
      B)
      "Have your child drink one large glass of water."
      C)
      "Bring your child into the clinic later today."
      D)
      "Hang up and call a poison control center hotline."
    4. A nurse is teaching a newly hired nurse about informed consent. Which of the following statements by the newly hired nurse indicates an understanding of the teaching?
      A)
      "My signature indicates that the client gave consent voluntarily to have the surgery."
      B)
      "My signature verifies that the nurse provided the client with information about the surgery."
      C)
      "My signature documents the accuracy of the information on the consent form."
      D)
      "My signature on the consent form validates the client’s concern about having surgery."
    Page 1 of 14

    Exam Review

    1. A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hr. Which of the following actions should the nurse take first?
      A)
      Offer pain medication.
      B)
      Auscultate bowel sounds.
      C)
      Administer an antiemetic.
      D)
      Palpate the abdomen.
    2. A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend?
      A)
      Drink a cup of hot cocoa before bedtime.
      B)
      Exercise 1 hr before bedtime.
      C)
      Eat a light carbohydrate snack before bedtime.
      D)
      Take a 30-min nap daily.
    3. A nurse is planning care for a client who has phlebitis of an IV site. Which of the following interventions should the nurse include?
      A)
      Apply a topical antibiotic ointment
      B)
      Initiate an infusion of 0.9% sodium chloride.
      C)
      Place a pressure dressing on the site.
      D)
      Apply warm, moist heat
    4. A nurse is caring for a client who asks about the use of active progressive relaxation therapy. Which of the following findings in the client's medical history is a contraindication to the use of this therapy?
      A)
      Acute back pain
      B)
      Chronic hypertension
      C)
      Generalized anxiety disorder
      D)
      Insomnia
    Page 2 of 14

    Exam Review

    1. A nurse is assessing a client's eyes for accommodation. Which of the following actions should the nurse take?
      A)
      Check the client's pupil reaction when focusing on distant and nearby objects.
      B)
      Observe the client's eyes for the six cardinal positions of gaze.
      C)
      Verify the client's ability to read letters on a Snellen eye chart.
      D)
      Test the client's eyes for reaction to light response.
    2. A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?
      A)
      Prepare the client for a central venous line.
      B)
      Administer the PN and fat emulsion separately.
      C)
      Obtain a random blood glucose daily.
      D)
      Change the PN tubing every 72 hr.
    3. A nurse is suctioning a client's tracheostomy tube. Which of the following actions should the nurse take during suctioning?
      A)
      Insert the catheter 2 cm (0.79 in) after meeting resistance.
      B)
      Suction the tube for 30 to 45 seconds during each pass.
      C)
      Apply suction while inserting the catheter.
      D)
      Allow 2 min between suction passes.
    4. A nurse is providing preoperative instructions to a client who has already signed an informed consent form. The client tells the nurse that she does not understand the procedure. Which of the following actions should the nurse take?
      A)
      Place a note on the front of the client's chart.
      B)
      Complete an incident report.
      C)
      Explain the procedure to the client.
      D)
      Notify the nursing supervisor.
    Page 3 of 14

    Exam Review

    1. A nurse is providing education about the common causes of polyuria to a client who has a urinary alteration. Which of the following client statements indicates an understanding of the teaching?
      A)
      “Polyuria can be caused by using antidepressants."
      B)
      "Polyuria can be caused by enlargement of the prostate gland."
      C)
      "Polyuria can be caused by trauma to the lower urinary tract."
      D)
      "Polyuria can be caused by drinking too much fluid."
    2. A nurse is teaching a client who has asthma about how to use a metered-dose inhaler (MDI). Which of the following statements by the client indicates an understanding of the teaching?
      A)
      "I will inhale for 2 seconds while depressing my inhaler."
      B)
      "I will wait 5 seconds before taking my second puff."
      C)
      "I will soak my inhaler in cold water weekly."
      D)
      "I will hold my breath for 10 seconds after I release the puff."
    3. A nurse is caring for a client who is receiving enteral tube feedings. Which of the following actions should the nurse take?
      A)
      Check tube placement once per day.
      B)
      Stop feedings if an ileus is detected.
      C)
      Keep the head of the bed elevated at 15°.
      D)
      Withhold feedings if the gastric residual volume is over 50 mL.
    4. A nurse is teaching a client about home safety while bathing. Which of the following instructions should the nurse include?
      A)
      Drain the water before getting out of the bathtub.
      B)
      Add bath oil to the water to moisturize skin.
      C)
      Fill the bathtub three-fourths of the way.
      D)
      Set the water heater to less than 76.6° C (170° F).
    Page 4 of 14

    Exam Review

    1. A nurse is caring for a client who is receiving continuous tube feedings via an NG tube and has a gastric residual volume of 120 mL. Which of the following actions should the nurse take?
      A)
      Decrease the rate of the infusion.
      B)
      Discontinue the tube feeding.
      C)
      Place the client in the lateral position.
      D)
      Recheck the gastric residual in 1 hr.
    2. A nurse is assessing a client who is receiving IV therapy for fluid volume deficit. Which of the following findings indicates a therapeutic response?
      A)
      Urine output 80 mL/4 hr
      B)
      Moist mucous membranes
      C)
      Increased thirst
      D)
      Increased hematocrit
    3. A nurse is providing teaching to an older adult client who has insomnia about ways to promote sleep. Which of the following instructions should the nurse include?
      A)
      Take two 30-min naps throughout the day.
      B)
      Drink a glass of wine prior to going to bed.
      C)
      Take a walk 1 hour before going to bed.
      D)
      Eat a small snack before going to sleep.
    4. A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at greatest risk for a pressure injury from a medical device?
      A)
      A client who has a chest tube
      B)
      A client who is receiving supplemental oxygen
      C)
      A client who is wearing a knee brace
      D)
      A client who has a surgical wound drain
    Page 5 of 14

    Exam Review

    1. A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse's priority?
      A)
      Schedule a support session for the client.
      B)
      Determine the client's reading ability.
      C)
      Explain the techniques of esophageal speech.
      D)
      Review the use of an artificial larynx with the client.
    2. A nurse is administering medications to a client and determines that a medication error has occurred. Which of the following actions should the nurse take?
      A)
      Notify the pharmacist.
      B)
      Complete a medication reconciliation form for the client.
      C)
      File an incident report.
      D)
      Have the nurse manager document the error in the medical record.
    3. A nurse is observing a client who is in four-point restraints for violent and self-destructive behavior. Which of the following actions should the nurse take when using four-point restraints?
      A)
      Assist the client with passive range of motion exercises every 3 hours.
      B)
      Attach the extremity restraint straps to the bed rails using a quick-release buckle.
      C)
      Assess the client every hour for circulation, possible injury, and readiness for discontinuation.
      D)
      Check the client's peripheral pulses and skin integrity every 15 min.
    4. A nurse is assessing a client whose health has declined. The client's extended family will be caring for the client in the client's home. Which of the following scenarios informs the nurse that the family has a clear knowledge of the impact on family functioning?
      A)
      The client's uncle will make all health care decisions for the client as well as assign family member roles.
      B)
      The client's brother is setting up an alternating schedule to give the primary caregiver some rest.
      C)
      The client's aunt will provide direct care for the client and other family members will provide financial support.
      D)
      The client's sister is relocating to the area to provide care for the client's children.
    Page 6 of 14