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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 is postoperative and has a BP of 88/48 mm Hg.
      B)
      A client who has received opioids and reports constipation.
      C)
      A client who is preoperative and needs to sign the consent form.
      D)
      A client who has a wound infection and a temperature of 38.9 degrees C (102 degrees F).
    2. A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)
      (SATA)
      A)
      Stop the transfusion.
      B)
      Administer epinephrine to the client.
      C)
      Administer oxygen to the client.
      D)
      Place the client in high-Fowler's position.
      E)
      Obtain a prescription for a diuretic.
    3. 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.
    4. A nurse is reviewing the home medications of a client who reports taking 4 teaspoons of liquid diphenhydramine at bedtime. How many mL should the nurse identify the client takes per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
      Correct Answer:20 mL
    Page 1 of 18

    Exam Review

    1. 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)
      Bring your child into the clinic later today.
      B)
      Have your child drink one large glass of water.
      C)
      Hang up and call a poison control center hotline.
      D)
      Induce vomiting in your child with syrup of ipecac.
    2. 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 verifies that the nurse provided the client with information about the surgery.
      B)
      My signature on the consent form validates the client's concern about having surgery.
      C)
      My signature documents the accuracy of the information on the consent form.
      D)
      My signature indicates that the client gave consent voluntarily to have the surgery.
    3. A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hours. Which of the following actions should the nurse take first?
      A)
      Palpate the abdomen.
      B)
      Auscultate bowel sounds.
      C)
      Offer pain medication.
      D)
      Administer an antiemetic.
    4. 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)
      Eat a light carbohydrate snack before bedtime.
      B)
      Drink a cup of hot cocoa before bedtime.
      C)
      Exercise 1 hour before bedtime.
      D)
      Take a 30-minute nap daily.
    Page 2 of 18

    Exam Review

    1. 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)
      Initiate an infusion of 0.9
      B)
      Apply a topical antibiotic ointment.
      C)
      Apply warm, moist heat.
      D)
      Place a pressure dressing on the site.
    2. 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)
      Chronic hypertension.
      B)
      Acute back pain.
      C)
      Acute heart failure.
      D)
      Chronic depression.
    3. 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.
    4. A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20 Which of the following is an appropriate action to include in the plan of care?
      A)
      Change the PN infusion bag every 48 hr.
      B)
      Obtain a random blood glucose daily.
      C)
      Prepare the client for a central venous line.
      D)
      Administer the PN and fat emulsion separately.
    Page 3 of 18

    Exam Review

    1. 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.
    2. 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.
    3. 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."
    4. 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."
    Page 4 of 18

    Exam Review

    1. 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.
    2. 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).
    3. A nurse is caring for a client who is receiving continuous tube feedings via an NG tube and has a gastric residual volume of 520 mL. Which of the following actions should the nurse take?
      A)
      Decrease the rate of the infusion.
      B)
      Discontinue the tube feeding.
      C)
      Recheck the gastric residual in 1 hour.
      D)
      Place the client in the lateral position.
    4. 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
    Page 5 of 18

    Exam Review

    1. 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.
    2. 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
    3. 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.
    4. 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.
    Page 6 of 18