Exam Review

A nurse is assigning client care to an RN and an LVN. Which of the following tasks must they assign to an RN only and NOT to an LVN. All parts of the answer must be restricted to an RN only. (Select all that apply)
(SATA)
A)
Creating a plan of care for a client who is recovering following a stroke.
B)
Assessing a pressure injury on a client who is on bed rest.
C)
Providing oral suctioning for a client who has pneumonia.
D)
Administer internal feeding to a client who has a nasogastric tube.
E)
Inserting a urinary catheter for a client who has urinary retention.
A nurse is caring for a young client who is actively dying of renal failure. What should the nurse do when caring for the dying client's family members?
A)
Inform the family members that it is time to bid farewell to the client.
B)
Request the family members not to talk about death to the client.
C)
Inform the family that the client may soon be out of danger.
D)
Encourage the family to leave the client to rest quietly without people around.
The nurse is demonstrating the professional value of integrity in which situation?
A)
Encourages the patient to make decisions about food selection choices on the menu.
B)
Demonstrates care and concern for a patient’s culture and beliefs.
C)
Performs patient assessment and records findings accurately.
D)
Plans to divide time for nursing tasks evenly among a group of patients.
The nurse has just graduated with a Bachelor of Science in Nursing and is eager to find a mentor at this early stage in her career. Which of the following individuals is most likely to be an appropriate mentor for the nurse?
A)
A colleague who graduated with honors at the same time as the novice nurse.
B)
An experienced nurse who was a preceptor in a previous clinical placement.
C)
The unit manager who is a personal friend of the novice nurse.
D)
The nurse educator in the hospital where the novice nurse has been hired.

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Exam Review

A client’s PaCO2 is abnormal on an ABG report. What does the nurse suspect as the most likely medical diagnosis?
A)
Sexually Transmitted Infection (STI).
B)
Chronic Renal Insufficiency or Failure (CRF).
C)
Chronic Obstructive Pulmonary Disease (COPD).
D)
Congestive Heart Failure (CHF).
A patient is admitted to the hospital with a diagnosis of alcoholism. The nurse should expect an order for
A)
Vitamin C 500mg oral daily.
B)
Thiamine hydrochloride (vitamin B1) 50mg intramuscular 3 times a day.
C)
Magnesium 20 mmol in 100ml normal saline via IV one time only.
D)
Albumin 25% 200ml via IV 1 time over 1 hour.
Which client likely faces a risk for the nursing diagnosis of Disturbed Sleep Pattern: Difficulty Remaining Asleep?
A)
A client who receives IV antibiotics every 3 hours.
B)
A client whose physical therapy has been scheduled for 4:30 p.m.
C)
A client who requires blood glucose checks 4 times daily.
D)
A client whose opioid analgesics result in central nervous system depression.
Nurses with varying levels of experience possess leadership skills. A graduate nurse walks out of the nurse manager’s office after a meeting. The graduate nurse reflects on the positive and negative feedback that she received from the manager regarding her three months working on the unit. What nursing leadership skill is best illustrated by the graduate nurse in this scenario?
A)
Problem-solving skills.
B)
Self-evaluation skills.
C)
Interpersonal skills.
D)
Communication skills.

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Exam Review

An appropriate nursing diagnosis for the family of a client dying of cancer whose members have expressed sorrow over the forthcoming loss would be
A)
Anticipatory Grieving related to the loss of a family member as evidenced by voicing sorrow and crying.
B)
Potential for Grieving related to future loss of family member and sorrow as evidenced by crying and insomnia.
C)
Dysfunctional Grieving related to loss of a family member as evidenced by behaviors indicating anxiety.
D)
Dysfunctional Grieving related to future loss of family member as evidenced by family’s age regression.
The nurse is working in a clinic and sees a resident of a long-term-care facility, age 82 years, who has come in to be checked by her physician. The caregiver accompanying her reports that the client has been displaying the following: drowsiness, excessive sleeping, decreased attention span, irritability, and signs of depression. The client’s daughter and family, who usually visit her, moved away from the area 6 weeks ago due to the husband’s job. The nurse suspects which problem?
A)
Disturbed sensory perception.
B)
Residential psychosis.
C)
Locked-in syndrome.
D)
Sensory deprivation.
A client with a diagnosis of colorectal cancer has been presented with her treatment options, but wishes to defer any decisions to her uncle, who acts in the role of a family patriarch within the client’s culture. The client’s right to self-determination is best protected by
A)
Educating the client about her right to autonomy.
B)
Holding a family meeting and encouraging the client to speak on her own behalf.
C)
Respecting the client’s desire to have the uncle make choices on her behalf.
D)
Revisiting the decision when the uncle is not present at the bedside.
The nurse is reviewing the laboratory findings of a patient to assess the patient’s nutritional status. The nurse understands the laboratory finding that is the best indicator of inadequate protein intake is a
A)
Low serum albumin.
B)
Low specific gravity.
C)
High hemoglobin.
D)
High blood urea nitrogen.

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Exam Review

The nurse is having an exceptionally busy shift on an obstetrical unit. Which of the following tasks is the nurse justified in delegating to an unlicensed care provider?
A)
Emptying a client’s Foley catheter bag and reporting the volume to the nurse.
B)
Assessing the size and quantity of clots that are in a client’s bedpan and informing the nurse.
C)
Giving an anti-inflammatory medication to a client who is eight hours postdelivery.
D)
Helping a first-time mother achieve a good latch when breast-feeding her infant.
A dying client tells the nurse that he doesn’t want to see his family because he doesn’t want to cause them more sadness. Which action by the nurse is most appropriate?
A)
Arrange a meeting between the family and the client.
B)
Educate the client on death and dying concepts.
C)
Allow the client time for quiet reflection.
D)
Help the client clarify his values.
After starting a blood transfusion, the nurse notes that the patient has fever, chills, and facial flushing. What should be the nurse’s first step?
A)
Stop the transfusion.
B)
Take the vital signs.
C)
Slow the transfusion.
D)
Contact the provider.
A group of nurses working in a long-term care facility fails to keep the narcotic medications in a locked secure location. The nurses also fail to document a count of the medications before and after each shift as indicated by the institution’s policies and procedures. These failures may result in disciplinary action against the
A)
Nurses’ licenses.
B)
Physician’s license.
C)
Pharmacist’s license.
D)
Facility’s license.

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Exam Review

A senior student has been elected president of the Student Nurses Association. Which of the following qualities is essential to being a nursing leader?
A)
Flexible.
B)
Independent.
C)
Physical stamina.
D)
Vulnerable.
A nurse is discussing sleep problems with a client. What type of foods should the nurse recommend to promote sleep?
A)
Three glasses of red wine.
B)
One cup of peanuts.
C)
One cup of hot chocolate.
D)
Cheese and crackers.
When the nurse inserts an ordered urinary catheter into the client’s urethra after the client has refused the procedure, and then the client suffers an injury, the client may sue the nurse for which type of tort?
A)
Battery.
B)
Invasion of privacy.
C)
Assault.
D)
Dereliction of duty.
A dying client is crying. She states, “Why me, Lord?” and “I can’t pray.” What would be the most appropriate nursing diagnosis based on this data?
A)
Low Self Esteem.
B)
Anticipatory Grieving.
C)
Ineffective Coping.
D)
Psycho-spiritual Distress.

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Exam Review

Which of the following statements is an appropriate nursing diagnosis for a client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion?
A)
Congestive Heart Failure related to edema as evidenced by edema and shortness of breath.
B)
Fluid Volume Deficit related to congestive heart failure, as evidenced by poor urinary output.
C)
Fluid Volume Excess related to loss of sodium and potassium as evidenced by low sodium and potassium levels shown in lab work.
D)
Extracellular Volume Excess related to heart failure, as evidenced by edema and orthopnea.
The client is in the intensive care unit following a stroke. The nurse is intervening in the plan of care to promote relaxation for the client and to prevent sensory overload. What independent nursing intervention would the nurse choose to do?
A)
Encourage visitors frequently throughout the day.
B)
Play music the client chooses.
C)
Sit in a chair next to the client and talk.
D)
Turn on the television to the Super Bowl.
A nurse is reviewing a new order on the Electronic Health Record. The dose of the medication is abnormally high. What would be the nurse’s best next action?
A)
Document concerns about the order.
B)
Refuse to administer the medication.
C)
Question the physician about the order.
D)
Administer the medication as ordered.
Which guideline does the nurse apply to discussion of sleep patterns with older adult clients?
A)
Older clients fall asleep more quickly than younger ones.
B)
The amount of stage 4 sleep increases as clients age.
C)
Total sleep time decreases as clients age.
D)
Circadian rhythms become more prominent as clients age.

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