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    Exam Review

    1. A nurse in a surgical suite notes documentation on a client's medical record that they have a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?
      A)
      Ensure sterilization of nondisposable items with ethylene oxide.
      B)
      Wrap monitoring cords with stockinette and tape them in place.
      C)
      Cleanse latex ports on IV tubing with chlorhexidine before injecting medication.
      D)
      Wear hypoallergenic latex gloves that contain powder.
    2. A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?
      A)
      Ask the client to consider a direct donation
      B)
      Withhold the blood transfusion.
      C)
      Request a consultation with the ethics committee
      D)
      Ask the client's family to intervene.
    3. A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?
      A)
      Alginate
      B)
      Gauze
      C)
      Transparent
      D)
      Hydrocolloid
    4. A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.)
      (SATA)
      A)
      Place the client in a room with negative-pressure airflow.
      B)
      Wear gloves when assisting the client with oral care.
      C)
      Limit each visitor to 2-hr increments.
      D)
      Wear a surgical mask when providing client care.
      E)
      Use antimicrobial sanitizer for hand hygiene.
    Page 1 of 10

    Exam Review

    1. A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next?
      A)
      Document the provider's statement in the medical record.
      B)
      Complete an incident report.
      C)
      Consult the facility's risk manager.
      D)
      Notify the nursing manager.
    2. A nurse is caring for a client who is having difficulty breathing. The client is supine and is receiving supplemental oxygen via a nasal cannula. Which of the following interventions should the nurse take first?
      A)
      Suction the client's airway.
      B)
      instruct the client to perform incentive spirometry every hour.
      C)
      Humidify the client's supplemental oxygen.
      D)
      Assist the client to an upright position.
    3. A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol?
      A)
      The client uses a wool blanket on their bed.
      B)
      The client identifies the location of a fire extinguisher.
      C)
      The client stores an extra oxygen tank on its side under their bed.
      D)
      The client has a weekly inspection checklist for oxygen equipment.
    4. A nurse is caring for a client who has limited mobility in their lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?
      A)
      Place the client in high-Fowler's position.
      B)
      Have the client use a trapeze bar when changing position.
      C)
      Massage areas of skin that are darker than the surrounding skin tissue with unscented lotion.
      D)
      Increase the client's intake of carbohydrates.
    Page 2 of 10

    Exam Review

    1. A nurse is assessing a client's readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?
      A)
      "I can concentrate best in the morning."
      B)
      "It is difficult to read the instructions because my glasses are at home."
      C)
      "I'm wondering why I need to learn this."
      D)
      "You will have to talk to my partner about this."
    2. A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching?
      A)
      Assign the client to a room with a negative airflow system.
      B)
      Use alcohol-based hand sanitizer when leaving the client's room.
      C)
      Clean contaminated surfaces in the client's room with a phenol solution.
      D)
      Have family members wear a gown and gloves when visiting.
    3. A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching?
      A)
      "I had a bowel movement, but I was able to save the urine."
      B)
      "I have a specimen in the bathroom from about 30 minutes ago."
      C)
      "I flushed what I urinated at 7:00 a.m. and have saved all urine since."
      D)
      "I drink a lot, so I will fill up the bottle and complete the test quickly."
    4. A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?
      A)
      "Most people are happy when their children grow up and leave home."
      B)
      "You should be proud that your children are becoming independent."
      C)
      "Maybe you should consider why you are feeling useless."
      D)
      "People in middle adulthood often find satisfaction in nurturing and guiding young people."
    Page 3 of 10

    Exam Review

    1. A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate?
      A)
      Droplet
      B)
      Airborne
      C)
      Contact
      D)
      Protective environment
    2. A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?
      A)
      "You should have an eye examination every 2 years."
      B)
      "You should receive a tetanus booster every 5 years."
      C)
      "You should receive a shingles vaccine when you are 70 years old."
      D)
      "You should receive a pneumococcal vaccine when you are 50 years old."
    3. A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all that apply.)
      A)
      Assist the client with a partial bed bath.
      B)
      Measure the client's BP after the nurse administers an antihypertensive medication.
      C)
      Test the client's swallowing ability by providing thickened liquids.
      D)
      Use a communication board to ask what the client wants for lunch.
      E)
      Irrigate the client's indwelling urinary catheter.
    4. A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
      A)
      Place a name tag on the body.
      B)
      Obtain the pronouncement of death from the provider.
      C)
      Remove tubes and indwelling lines.
      D)
      Wash the client's body.
      E)
      Ask the client's family members if they would like to view the body.
    Page 4 of 10

    Exam Review

    1. A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client?
      A)
      Have the client wear a mask when receiving visitors.
      B)
      Wear a gown when caring for the client.
      C)
      Assign the client to a room with negative-pressure airflow exchange.
      D)
      Limit the client's time with visitors to no more than 30 min per day.
    2. A nurse is caring for a client with a diagnosis of terminal cancer. Which of the following statements by the client should indicate to the nurse that the client is ready to hear information regarding palliative care?
      A)
      "I am ready to learn about chemotherapy to help cure my cancer."
      B)
      "I just want you to give me something to get this over with soon."
      C)
      "I know that many people have recovered fully from cancer, and so will I."
      D)
      "I want you to tell me about measures available to keep me comfortable."
    3. A nurse is caring for a client who is postoperative. When the nurse prepares to change the client's dressing, they say, "Every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action?
      A)
      Encourage the client to relax and take deep breaths during the dressing change.
      B)
      Educate the client about the importance of the dressing change to prevent infection.
      C)
      Assist the client to a comfortable position for the dressing change.
      D)
      Administer pain medication 45 min before changing the client's dressing.
    4. A nurse enters a client's room and finds them on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?
      A)
      "Incident report completed."
      B)
      "Client climbed over the side rails."
      C)
      "Client found lying on floor."
      D)
      "Client was trying to get out of bed."
    Page 5 of 10

    Exam Review

    1. A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?
      A)
      Bend at the waist.
      B)
      Stand close to the cabinet when lifting it.
      C)
      Use the back muscles for lifting.
      D)
      Keep the feet close together.
    2. A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care?
      A)
      Wrap blankets around all four sides of the bed.
      B)
      Apply restraints during seizure activity.
      C)
      Place the client in a supine position during seizure activity.
      D)
      Have a tongue depressor at the client's bedside.
    3. A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate?
      A)
      Ambulating a client who is postoperative
      B)
      Inserting an indwelling urinary catheter for a client
      C)
      Demonstrating the use of an incentive spirometer to a client
      D)
      Confirming that a client's pain has decreased after receiving an analgesic
    4. A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?
      A)
      Hypotension
      B)
      Weak, thready pulse
      C)
      Slow capillary refill
      D)
      Distended neck veins
    Page 6 of 10