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    Exam Review

    1. A facility is planning to implement an update to the electronic health record. This update is designed to facilitate documentation of critical changes in clients' condition to save time that nurses spend when documenting these changes. How could this information be used best if the nurse informaticist set the system up correctly?
      A)
      Security and Privacy
      B)
      Gamification
      C)
      Data Analytics
      D)
      Copy and Paste
    2. A student nurse is assigned a patient to provide care for throughout the day. Which of the following actions would violate client confidentiality?
      A)
      Providing a detailed SBAR report to the primary nurse
      B)
      Collaborating with the patient care technician for hygiene care.
      C)
      Discussing the client's medications with the clinical instructor.
      D)
      Writing the client's initials on the student care plan.
    3. A client has developed edema in her lower legs and feet prompting her physician to prescribe furosemide, a diuretic medication. After the client has begun this new medication, what should the nurse anticipate as a normal finding?
      A)
      Transient incontinence and increased urine production
      B)
      Increased urine concentration
      C)
      Increased output of dilute urine
      D)
      A risk of urinary tract infections
    4. A client with a viral upper respiratory infection tells the nurse, "I am so angry because the nurse practitioner would not give me any antibiotics." What would be the most appropriate response by the nurse?
      A)
      "Let me teach you about antibiotics and their usage."
      B)
      "Let me talk to the provider and see what we can do."
      C)
      "Why do you think you need an antibiotic?"
      D)
      “I understand your frustration. You need an antibiotic.”
    Page 1 of 13

    Exam Review

    1. The nurse has received a report for the following patients. Which patient should be seen first?
      A)
      89-year-old with dementia and NG tube with continuous tube feeding
      B)
      73-year old with hypoactive bowel sounds one day post cholecystectomy.
      C)
      43 year old with anorexia and nausea for two days who is tolerating a clear liquid diet
      D)
      65 year old with who has dysphagia after suffering from a stroke who is NPO
    2. A student nurse is assessing their patient who is NPO due to a recent surgery. The provider comes in the room to see the patient and states that the patient is cleared to start a full liquid diet. What is the best action by the student nurse?
      A)
      Ensure the patient is safe and leave to get them some water.
      B)
      Contact dietary to order the patient a full liquid meal.
      C)
      Request that the provider write the order in the chart.
      D)
      Record the information in the patient chart.
    3. Which of the following patients are at highest risk for developing a skin injury caused by shearing?
      A)
      A patient who is lying on wrinkled sheets.
      B)
      A patient who is pulled up in the bed by the nurse
      C)
      A patient who is frequently incontinent.
      D)
      A patient who is noted to have slough tissue
    4. The nurse is assessing the patient's output for the shift. What finding is most concerning?
      A)
      Green, soft stool after the patient received antibiotics
      B)
      Large, loose stool after the patient received a laxative
      C)
      Dry, hard stool from a patient receiving opiates.
      D)
      Black tarry stool from a patient receiving an anticoagulant
    Page 2 of 13

    Exam Review

    1. The following procedures have been ordered and implemented for a hospitalized patient. Which procedure carries the greatest risk for a healthcare-associated infection?
      A)
      Placing an indwelling urinary catheter
      B)
      Administering medications through an NG tube
      C)
      Changing a sacral wound dressing
      D)
      Replacing an ostomy appliance
    2. The following procedures have been ordered and implemented for a hospitalized patient. Which procedure carries the greatest risk for a healthcare-associated infection?
      A)
      Placing an indwelling urinary catheter
      B)
      Administering medications through an NG tube
      C)
      Changing a sacral wound dressing
      D)
      Replacing an ostomy appliance
    3. The nurse is providing indwelling catheter care for a patient who is uncircumcised. What intervention will help prevent a catheter associated urinary tract infection?
      A)
      Obtain daily urine specimens by opening the collection drainage system.
      B)
      Keep the urine collection bag below the level of the bladder at all times.
      C)
      Retract the foreskin to clean the catheter tubing and meatus outward leaving the foreskin retracted.
      D)
      Change the indwelling catheter at least every one week.
    4. The nurse is attempting to develop a therapeutic nurse-client relationship with a newly admitted client. What expectations does the nurse have when developing the relationship?
      A)
      The relationship occurs spontaneously.
      B)
      It is based on the needs of the nurse.
      C)
      The nurse and client will have a social relationship.
      D)
      The nurse is accountable for the outcome.
    Page 3 of 13

    Exam Review

    1. The nurse is providing oral care to a sedated patient. What intervention is most important to implement with this patient?
      A)
      Avoid using your fingers to open the mouth.
      B)
      Apply moisturizer to the oral mucosa and lips.
      C)
      Brush the teeth with a soft bristled toothbrush
      D)
      Use a toothbrush with a suction attachment
    2. You are providing care for a patient who had an ileostomy placed one week ago after a bowel resection. You note the following findings during your assessment (see chart below): Stoma Assessment Stoma is protruding 2cm, is red and moist. Peristomal area is clean and intact. Output Liquid stool that is malodorous. Gas present in the appliance. General Status Patient is avoiding looking at the ileostomy during care. Laboratory Data Potassium 3.6 mEq/L (normal 3.5 to 5 mEq/L) Sodium 137 mEq/L (normal 135 to 145 mEq/L) Creatinine 0.9 mg/dL (normal 0.6 to 1.2 mg/dL) What finding is most concerning to the nurse?
      A)
      Output assessment
      B)
      General Status
      C)
      Stoma assessment
      D)
      Laboratory data
    3. The nurse is providing care for the following patients. Which patient is at highest risk of developing an infection?
      A)
      46-year-old with a low neutrophil count
      B)
      59-year-old seven days post abdominal surgery
      C)
      82-year-old with a history of leukemia ten years ago
      D)
      62-year-old on antibiotic therapy
    4. You have received a report and are providing skin care for the following patients. Which patient do you want to assess first?
      A)
      A 58-year-old patient with uncontrolled diabetes mellitus type two and intact skin.
      B)
      A 48-year-old patient with poor nutrition, warmth and edema to the coccyx.
      C)
      An 82-year-old patient with a surgical incision and approximated wound edges.
      D)
      A 69 year old patient with a colostomy and blanchable erythema to the sacrum.
    Page 4 of 13

    Exam Review

    1. A nurse makes a medication error and fills out an incident report. What will the nurse do with the incident report once it is filled out?
      A)
      Take the report home and keep it locked up.
      B)
      Place the report in the client's medical record
      C)
      Maintain the report according to agency policy
      D)
      Email the report to their nursing supervisor
    2. A client with urine retention related to a complete prostatic obstruction requires a urinary catheter to drain the bladder. Which type of catheter is most appropriate for a client that has an obstructed urethra?
      A)
      Straight catheter.
      B)
      Indwelling urethral catheter
      C)
      Suprapubic catheter
      D)
      Intermittent urethral catheter
    3. After applying pneumatic compression devices to bilateral lower extremities on a patient who is on bedrest, the patient asks what the purpose is of the device. How should the nurse respond to best address the patient's question?
      A)
      "These help to get rid of clots that are in your legs that can cause problems."
      B)
      "These help circulate air and provide compression to your legs."
      C)
      "These will help you to perform passive range of motion to your legs."
      D)
      "These will help to reduce the risk of developing a venous thrombus."
    4. A patient is on isolation for neutropenia. What statement made by the patient requires additional education from the nurse?
      A)
      "I will avoid individuals who were recently vaccinated."
      B)
      “I can have visitors so long as they are healthy."
      C)
      “I can have fresh flowers brought in.”
      D)
      “I should avoid soft cheese.”
    Page 5 of 13

    Exam Review

    1. A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. Which of the following statements would be best for the nurse to make?
      A)
      "Everyone knows there are others who can chair this committee better than me."
      B)
      "It's just not the right time for me to do this."
      C)
      “I decline the opportunity at this time.”
      D)
      "Can you tell me why you chose me?"
    2. A nurse enters a patient's room and finds that the patient has fallen on the way to the bathroom. What action should be implemented first?
      A)
      Assess the patient.
      B)
      File a safety event report
      C)
      Place the patient on fall precautions.
      D)
      Get the patient back to bed.
    3. The nurse is providing care to a patient who has tested positive for tuberculosis. The patient is moved into an airborne isolation room and the patient asks. "Why do I need to be moved into this new room?" How should the nurse respond?
      A)
      "This new room has negative pressure and does six to twelve air changes an hour and disposes the air outside to reduce the infection potential in other patients. I also have to wear this surgical mask"
      B)
      "It sounds like you have some questions about your new diagnosis. What are you most concerned about?"
      C)
      "Tuberculosis can seriously impair the lungs and requires a long course of antibiotics to treat it
      D)
      “Tuberculosis is a small particle that can spread through the air. This new room has a special filter that reduces the spread of the bacteria through the air."
    4. A nurse is preparing to bathe a client with dyspnea. Which of the following actions should the nurse plan to take?
      A)
      Avoid bathing this patient until they are stable.
      B)
      Only bathe the perineal area.
      C)
      Perform the bath in a semi-Fowler's position.
      D)
      Delegate the task to the assistive personnel.
    Page 6 of 13