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    Exam Review

    1. A client expresses concern to the nurse about their high stress levels following a recent diagnosis of hypertension. How should the nurse respond?
      A)
      "Focusing on your medication and diet regimen will help reduce stress levels."
      B)
      "People are diagnosed with hypertension dally. Why are you feeling stressed?"
      C)
      "A new diagnosis is stressful. What ways have you reduced stress in the past?"
      D)
      "Try distracting yourself from your stress level. Avoiding it may make it go away."
    2. A nurse is caring for an older adult client diagnosed with osteoarthritis. The client states, "My pain right now is a 4 out of 10. What action(s) should the nurse take at this time? Select all that apply.
      (SATA)
      A)
      Administer ordered analgesics as prescribed.
      B)
      Encourage the client to practice relaxation exercises.
      C)
      Apply warm or cold compresses to the client's affected joints.
      D)
      Wait to see if the pain increases before intervening.
      E)
      Recommend the client to remain in bed until pain improves.
    3. A hospitalized client wants to complete an advance directive to change their status to do not resuscitate after hearing they have a terminal illness. How should the nurse respond?
      A)
      "I think you should give it a little more time since you just got this diagnosis."
      B)
      "I will speak to your healthcare provider to inform them about your request."
      C)
      "You should check with your family before you make such a big decision."
      D)
      "Once you create the advance directive, It can't be changed for a whole year."
    4. A nurse is preparing to administer acetaminophen 15 mg/kg dose by mouth to a client who weighs 82 lbs. Available is acetaminophen 160 mg/5 mL. How many mL should the nurse administer? mL (If needed, round the answer to the nearest tenth.)
      Correct Answer:17.5 mL
    Page 1 of 14

    Exam Review

    1. The nurse teaches the caregivers of a toddler about normal sleep requirements and patterns. Which statement made by the caregivers indicates effective learning has occurred?
      A)
      "We should expect our toddler to nap until they are 5 years old."
      B)
      "Toddlers require 15-16 hours of sleep daily to promote growth."
      C)
      "Bedtime will continue to be difficult due to their need for autonomy,"
      D)
      "Approximately 50% of a toddler's sleep is rapid eye movement."
    2. The nurse administers an intravenous (IV) analgesic to a client with abdominal pain. Which assessment finding should the nurse identify as a complication of IV pain medication therapy?
      A)
      Pain rating 3/10
      B)
      Oxygen saturation 91%
      C)
      Blood pressure 149/86
      D)
      Temperature 98.7 F (37 C)
    3. The nurse is planning care for a client with insomnia. Which therapeutic action should the nurse include in the plan of care?
      A)
      Place the client close to the nurse's station for monitoring.
      B)
      Encourage one big meal before bed to produce drowsiness.
      C)
      Eliminate any activities that are not important overnight.
      D)
      Turn on a soothing television channel for relaxation overnight.
    4. The nurse assesses a deceased client's body to determine readiness for viewing by the family. Which assessment finding(s) indicate the body is ready for viewing by the family? Select all that apply.
      (SATA)
      A)
      The client is covered with a clean sheet.
      B)
      The head of the bed is elevated slightly.
      C)
      The client's hair is uncombed.
      D)
      The client has been bathed.
      E)
      The client's eyes are open.
    Page 2 of 14

    Exam Review

    1. A client recovering from a colon resection with a colostomy placement refuses to observe colostomy care when the nurse performs it. What action should the nurse take at this time?
      A)
      Acknowledge the behavior and assess their feelings about the colostomy.
      B)
      Remind the client they will need to look eventually, so it's best to start now.
      C)
      Document the refusal and change the subject to avoid client discomfort.
      D)
      Ask a family member to encourage the client to look at the colostomy.
    2. The nurse performs postmortem care on a client. What is the primary rationale for the nurse slightly elevating the head of bed during this process?
      A)
      To prevent evacuation of the bowels and bladder.
      B)
      To prepare the body for viewing by the family.
      C)
      To manage the pooling of blood in the head.
      D)
      To reduce the amount of work for the mortician.
    3. A nurse is planning discharge teaching for a client with a new diagnosis of ulcerative colitis. Which factor should the nurse recognize as having the biggest impact on the client's ability to cope after discharge?
      A)
      The family's ability to monitor the client's changing health status
      B)
      The family's ability to provide emotional and mental support
      C)
      The family's ability to manage the client's medication regimen
      D)
      The family's ability to take care of the client's special diet needs
    4. Client profile Name: James Reyes Provider: PD, MD Code Status: Full Code Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
    Page 3 of 14

    Exam Review

    1. A nurse is caring for a client recently diagnosed with a terminal illness. Which behavior indicates the client is in the anger stage of the Kübler-Ross model?
      A)
      "Why is this happening to me? This is completely unfair!"
      B)
      "I'll do anything to live long enough to see my son graduate."
      C)
      "This can't be happening to me and the tests must be wrong."
      D)
      "I've made peace with this and I'm ready for what comes next."
    2. A nurse provides guidance to the caregiver of a client with progressing Alzheimer's disease. What should the nurse plan to teach the caregiver to help them manage their stress? Select all that apply.
      A)
      Recommend the caregiver seek counseling or therapy services
      B)
      Provide the caregiver with information on respite care services
      C)
      Advise the caregiver to cherish the time they have with their loved one
      D)
      Suggest that the caregiver engage in regular physical activity
      E)
      Encourage the caregiver to join an Alzheimer's support group for families
    3. The nurse is caring for a client scheduled for a cholecystectomy. What action should the nurse take before transporting the client to the preoperative area?
      A)
      Provide the client with an emesis basin.
      B)
      Inform the family about surgery results.
      C)
      Complete the preoperative checklist.
      D)
      Administer the sedation medication.
    4. A preoperative nurse is implementing care and notices the client's consent form was signed yesterday. What action should the nurse take before proceeding?
      A)
      Ask the client to sign the consent form again for confirmation of the procedure.
      B)
      Confirm the client has understanding of the procedure and still agrees to it.
      C)
      Assume the surgeon explained everything and continue preoperative care.
      D)
      Scan or file the consent form in the client's medical record and proceed.
    Page 4 of 14

    Exam Review

    1. Which is a physiological cue of acute severe pain?
      A)
      Decreased respiratory rate
      B)
      Decreased muscle tension
      C)
      Increased blood pressure
      D)
      Pupil constriction
    2. A nurse is caring for a client who reports insomnia due to chronic leg pain. Which action by the nurse is most appropriate?
      A)
      Ask if the client is currently taking any pain medications.
      B)
      Encourage the client to do vigorous exercise before bedtime.
      C)
      Ask the client to keep a diary for the next two weeks.
      D)
      Encourage the client to try a sleep aid before bedtime.
    3. The nurse teaches an older adult client about their new diagnosis of heart disease. Which statement(s) by the client indicate that further teaching is needed? Select all that apply.
      A)
      "Exercise and dietary changes can help my heart disease from progressing."
      B)
      "The feeling of lightheadedness when standing up is nothing to worry about."
      C)
      "I should take my blood pressure regularly to manage my heart disease."
      D)
      "I really need to stop smoking and lose some weight to help my heart."
      E)
      "I should take my medication if I feel the symptoms of high blood pressure."
    4. Which is a complication of chronic pain?
      A)
      Depression
      B)
      Bradycardia
      C)
      Euphoria
      D)
      Diarrhea
    Page 5 of 14

    Exam Review

    1. The nurse is caring for an older adult client with delirium. Which assessment finding(s) should be identified as a likely contributor to delirium? Select all that apply.
      A)
      Immobility with a bed rest order
      B)
      History of Alzheimer's disease
      C)
      Sleep deprivation
      D)
      Decreased white blood cell count
      E)
      Opioid medication use
    2. The nurse is providing palliative care for a client with terminal pancreatic cancer. What intervention should the nurse prioritize in the care of this client?
      A)
      Pain control
      B)
      Nutritional support
      C)
      Emotional support
      D)
      Hospice education
    3. During an assessment, a client reports difficulty concentrating and frequent mood swings. The nurse identifies that the client may have sleep deprivation. What additional finding supports this concern?
      A)
      Reports of vivid dreams and restful sleep
      B)
      Observed irritability and poor short-term memory
      C)
      Statements of increased physical endurance
      D)
      Elevated pain threshold during procedures
    4. What is the primary focus of the intraoperative phase of perioperative nursing?
      A)
      Monitoring the client's nutritional intake
      B)
      Preparing discharge instructions
      C)
      Ensuring client safety during the procedure
      D)
      Administering oral medications
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