Exam Review

The nurse has received hand-off report on a client that is being admitted to the unit from the post-anesthesia care unit (PACU). Which is the priority action for the nurse to take when the client arrives to the unit?
A)
Orient the client to the room
B)
Assure the call light is within reach
C)
Call the provider for orders
D)
Assess vital signs
The following arterial blood gas (ABG) results indicates? pH-7.19 PaCO2-65.8 mmHg Pa02-75 mmHg HCO3-26.2 mEq/L BE-(+1.6) 02 Sat - 90%
A)
Metabolic acidosis
B)
Metabolic alkalosis
C)
Normal ABG results
D)
Respiratory acidosis
The nurse is caring for a client that was admitted with nausea/vomiting, restlessness, dry oral mucosa, and extreme thirst. The nurse understands that the client has which electrolyte imbalance?
A)
Hyperphosphatemia
B)
Hyperkalemia
C)
Hypocalcemia
D)
Hypernatremia
A nurse is caring for several clients with wounds. Which of the following clients is at the highest risk for delayed wound healing?
A)
Client who urinates frequently due to diuretic therapy
B)
Client with limited mobility recovering from knee surgery
C)
Client who is NPO one day before abdominal surgery
D)
Client with diabetes, obesity and current cigarette smoker

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Exam Review

The nurse is performing a complete bed bath for a comatose client. What action best communicates caring to this client?
A)
Having another nurse assist to perform the bed bath
B)
Making sure that daily hygiene was completed on time
C)
Speaking in a calm voice and using gentle touch
D)
Maintaining eye contact with the client throughout
The nurse is collaborating with the dietitian about a client with a stage 3 pressure ulcer. After the collaboration the nurse orders a meal plan that includes increased
A)
Vitamin E.
B)
Protein.
C)
Fats.
D)
Carbohydrates.
The nurse is reviewing the labs for a client. The calcium level is 7.5 mg/dL. The nurse knows this value represents hypocalcemia. What symptoms would the nurse expect to find in this client? Select all that apply.
(SATA)
A)
Positive Trousseau's sign
B)
Muscle weakness
C)
Decreased muscle tone
D)
Polyuria
E)
Hyporeflexia
When documenting, what guidelines should be followed? Select all that apply.
(SATA)
A)
Documentation should express the nurse's opinion.
B)
Documentation should include abbreviations when possible.
C)
Documentation should be complete.
D)
Documentation should be factual.
E)
Documentation should be accurate.

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Exam Review

Which is an unintended effect of elderspeak?
A)
Active listening
B)
Short-term memory loss
C)
Resistance to care
D)
Compliance
The nurse notes an oozing, shallow, irregularly shaped ulcer on a client's lower leg. The surrounding tissue is bruise-like in appearance. The nurse correctly documents this as:
A)
Deep tissue injury
B)
Stage 2 pressure ulcer
C)
Arterial ulcer
D)
Venous ulcer
With appropriate instruction, which tasks are appropriate to delegate to an unlicensed assistive personnel (UAP)? Select all that apply.
A)
Evaluating fluid balance status
B)
Assisting with client ambulation
C)
Determining need for assistive devices
D)
Measurement of intake and output
The nurse comes onto shift. Which client should be assessed first?
A)
Anxious client awaiting a procedure reporting new onset of chest pressure
B)
Angry client dissatisfied with the room and demands to speak to the unit director
C)
Status post surgical client complaining of pain 4/10 at a large incision site
D)
Client admitted with a bowel obstruction who has nausea and vomiting

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Exam Review

The nurse is caring for a client that has had a nasogastric tube to low wall suction for 5 days. Which acid/base imbalance would the nurse expect to see in this client?
A)
Metabolic acidosis
B)
Respiratory acidosis
C)
Metabolic alkalosis
D)
Respiratory alkalosis
When evaluating a plan of care, the nurse reviews the expected outcomes for the client. Which expected outcome is realistic for a client with a pelvic fracture on ordered bed rest?
A)
Client will transfer self to the bedside commode by the end of shift.
B)
Client will use a walker to the bathroom by the end of the shift.
C)
Client will ambulate in the hallway two times by the end the shift.
D)
Client will turn self in bed with assistance by the end of the shift.
Which statement is the best example of critical thinking as taught by a nurse educator to a nursing student?
A)
"This intervention is how we have alway done it."
B)
"Think about several different interventions you could use with this client."
C)
"Don't be concerned about finding a rationale to support your decision."
D)
"Think subjectively when drawing inferences about your client."
A client with a suspected pneumonia presents to the emergency department. Which diagnostic test does the nurse anticipate being ordered for this client?
A)
Computed tomography (CT) scan of the chest
B)
Chest X-ray
C)
Ultrasound
D)
Magnetic resonance imaging (MRI) of the chest

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Exam Review

The charge nurse prepares for client care by making assignments. They have two RN's and one LVN on the shift. Which client should the charge nurse assign to the LVN?
A)
A client who is having difficulty breathing with a diagnosis of a fractured femur.
B)
A client with a total knee replacement and will be discharged tomorrow.
C)
A new admission with a diagnoses of Congestive Heart Failure.
D)
A transfer client from the ICU with a diagnoses of End-stage Renal Failure.
During the initial home visit, the nurse informs the client that the visits are expected to last for 6 weeks. Which phase of the helping relationship is the nurse in with this client?
A)
Working phase
B)
Pre-interaction phase
C)
Orientation phase
D)
Termination phase
The nurse is administering 0.45% NaCl (sodium chloride) intravenously to a client. What effect will this have on the client's body?
A)
increase interstitial volume
B)
fluid will move in to cells
C)
fluid will move out of cells
D)
increase sodium levels
The nurse notices the client's nares have become dry after receiving 4 liters of oxygen via nasal cannula. What is an appropriate intervention?
A)
Ensure that the device is positioned and attached appropriately
B)
Use a cotton tip swab to apply petroleum to the nares
C)
Switch the oxygen delivery device to a simple face mask
D)
Consult with respiratory therapy about adding humidification

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Exam Review

Identify each assessment finding that is an example of subjective data. Select all that apply.
A)
Temperature 101° F
B)
Moist skin
C)
Heart rate 90
D)
Pain 3/10
E)
Nausea
The nurse enters the room of a client who has fallen out of bed and is on the floor. The provider is notified and it is determined that the client was not injured. What is the best way to document this incidence in the nursing progress notes?
A)
"Client found on floor despite repeated reminders to use call light. No injuries noted. Soft wrist restraints applied per provider orders."
B)
"Client discovered lying on floor in room. Provider called to bedside. No injuries noted. Client returned to bed with bed alarm on, call light in reach."
C)
"Client fell out of bed. Provider notified. No apparent injuries. Client reminded to use call light. Side rails up x 4."
D)
"Client discovered out of bed on the floor after side rails left down. Client not injured. See incident report."
E)
Nausea
A Venturi mask is unique from other oxygen delivery methods because it:
A)
allows oxygen to reach lower into the lungs
B)
contains an oxygen reservoir bag
C)
administers the highest percentage of oxygen
D)
has a flow control meter attached
A client reports a new onset of abdominal discomfort to the nurse. What is the most appropriate intervention at this time?
A)
Administer standing PRN pain medication
B)
Reposition the client to the prone position
C)
Perform an assessment of the abdomen
D)
Request an order for an abdominal x-ray

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