Exam Review

A client with a seizure disorder is seen at the clinic for a follow-up visit and a prescription renewal for phenytoin. Which assessment finding warrants immediate intervention by the nurse?
A)
Chronic insomnia.
B)
Puffy, bleeding gums.
C)
Double vision.
D)
Blood pressure 100/78 mm Hg.
A young adult client with osteoarthritis of both knees expresses the desire to continue daily walks in the park with friends. How should the nurse respond?
A)
Encourage continued maintenance of the walking routine.
B)
Advise less weight-bearing to prevent joint destruction.
C)
Recommend walking indoors for improved stability and safety.
D)
Suggest a calcium supplement along with continued walking.
The nurse is preparing a client for surgery who was admitted to the emergency center following a motor vehicle collision. The client has a fracture of the femur and is bleeding at the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin subcutaneously daily. Which is the priority nursing action?
A)
Notify the healthcare provider of the client’s medication history.
B)
Ensure that the potential for bleeding is explained to the client.
C)
Have the client sign the surgical and transfusion permits.
D)
Observe the heparin injection sites for signs of bruising.
A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?
A)
Lower back pain and hypotension.
B)
Delayed painful rash with urticaria.
C)
Acute rhinitis and nasal stuffiness.
D)
Arthritic joint changes and chronic pain.

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Exam Review

A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?
A)
Lower back pain and hypotension.
B)
Delayed painful rash with urticaria.
C)
Acute rhinitis and nasal stuffiness.
D)
Arthritic joint changes and chronic pain.
The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the client for the healthcare provider?
A)
Lumbar puncture.
B)
Skull radiography.
C)
Magnetic resonance imaging (MRI).
D)
Computerized tomography (CT) scan.
A nurse is caring for a patient who has been admitted to the hospital with a suspected diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the patient for?
A)
Lumbar puncture
B)
Skull radiography
C)
Magnetic resonance imaging (MRI)
D)
Computerized tomography (CT) scan
A nurse is educating a patient with Type 2 diabetes mellitus and peripheral neuropathy. What advice should the nurse give?
A)
Shoes should be worn outside the house, but it is fine to be barefoot inside.
B)
Family members can assist with regular foot exams.
C)
Heating pads are useful if used on the lowest setting.
D)
Aching feet may be soaked in lukewarm water for one hour or more.

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Exam Review

An overweight young adult diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. The patient reports feeling very weak and jittery. What actions should the nurse take? (Select all that apply)
(SATA)
A)
Check fingerstick glucose level.
B)
Assess skin temperature and moisture.
C)
Administer a PRN dose of regular insulin.
D)
Document anxiety on the surgical checklist.
E)
Measure pulse and blood pressure.
The nurse is providing discharge teaching to an older adult patient hospitalized for treatment of venous leg ulcers. Which instructions should the nurse include in the teaching plan? (Select all that apply.)
(SATA)
A)
Eat a diet that is high in protein and vitamins A and C.
B)
Maintain bed rest as much as possible.
C)
Keep legs elevated when sitting or lying down.
D)
Inspect ankles daily for areas of darkening skin.
E)
Apply intermittent cold compresses four times daily.
A patient with small cell carcinoma of the lung is admitted with syndrome of inappropriate antidiuretic hormone (SIADH). The patient’s serum sodium level increases from 120 mEq/L to 125 mEq/L as they respond to treatment. Based on this finding, what intervention should the nurse implement?
A)
Maintain the prescribed fluid restriction.
B)
Withhold the next scheduled dose of treatment.
C)
Increase neurologic checks to every 2 hours.
D)
Assess for increasing fluid volume overload.
The nurse is assessing a patient’s understanding of the DASH (Dietary Approaches to Stop Hypertension) diet. Which patient behavior suggests adherence to this diet?
A)
The patient exclusively consumes lactose-free dairy products.
B)
The patient meticulously cleans and peels all fresh fruits and vegetables.
C)
The patient enjoys fat-free yogurt as an occasional snack.
D)
The patient has eliminated grains from their diet.

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Exam Review

What information should the nurse include in the teaching plan for a patient diagnosed with gastroesophageal reflux disease (GERD)?
A)
The patient should adjust their food intake to three full meals per day with no snacks.
B)
The patient should avoid participating in any aerobic exercise programs.
C)
The patient should sleep without pillows at night to maintain neck alignment.
D)
The patient should wear loose, comfortable clothing to minimize symptoms.
The nurse is teaching a patient with chronic obstructive pulmonary disease (COPD) about huff coughing to clear secretions. During the patient’s return demonstration, the patient exhales using pursed lips. What should the nurse do next?
A)
Advise the patient that the procedure is being performed correctly.
B)
Tell the patient to take several shallow breaths before the next exhalation.
C)
Instruct the patient to inhale deeply and then quickly and forcefully exhale 2 to 3 times.
D)
Position the patient in the semi-Fowler’s position and apply oxygen.
The healthcare provider prescribes diagnostic tests for a patient whose chest x-ray indicates pneumonia. Which diagnostic test should the nurse prepare the patient for?
A)
Computerized tomography (CT) of the chest.
B)
Arterial blood gases (ABG).
C)
Sputum culture and sensitivity.
D)
Blood cultures.
The nurse is providing discharge teaching to an older patient hospitalized for treatment of venous leg ulcers. What instructions should the nurse include in the teaching plan? (Select all that apply.)
A)
The patient should eat a diet high in protein and vitamins A and C.
B)
The patient should keep their legs elevated when sitting or lying down.
C)
The patient should maintain as much bed rest as possible.
D)
The patient should inspect their ankles daily for areas of darkening skin.
E)
The patient should apply intermittent cold compresses four times daily.

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Exam Review

Which group of foods should the nurse recommend for patients with a strong family history of colon and rectal cancers?
A)
Lean beef, salads, and baked potatoes.
B)
Potatoes, low-fat breads, and applesauce.
C)
Oatmeal, raisins, and fruit with skin.
D)
Chicken, rice, and wheat products.
While providing care for a patient with Guillain-Barre syndrome, the nurse conducts a neurological assessment every four hours. Which finding from the assessment requires immediate intervention by the nurse?
A)
Profuse sweating.
B)
Weakness in the lower legs.
C)
Loss of sensation at T-8.
D)
Leg pain that worsens at night.
A patient with gouty arthritis is experiencing tenderness and swelling in the right ankle and big toe. The nurse notes that the inflammation extends above the ankle area. The patient has been prescribed colchicine and indomethacin. What should the nurse include in the discharge teaching?
A)
Consume high-protein foods to reach an ideal body weight.
B)
Drink at least eight cups (1920 mL) of water each day.
C)
Use an electric heating pad when the pain is severe.
D)
Encourage active range of motion exercises to prevent stiffness.
The healthcare provider prescribes penicillin 200,000 units intramuscularly for a patient with pneumonia. The available vial is labeled “Penicillin 500,000 units/mL”. How much penicillin should be administered to the patient? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

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Exam Review

An elderly patient is admitted with an acute onset of diverticulitis, and intravenous antibiotic therapy is started. What should the nurse do next?
A)
Elevate the head of the bed.
B)
Initiate a bowel prep protocol for surgery.
C)
Educate the patient on increasing dietary fiber.
D)
Maintain the patient’s NPO status.
An hour after administering 60 mg of furosemide intravenously (IV), which assessments should the nurse perform to determine the patient’s response to treatment? (Select all that apply.)
A)
Urinary output.
B)
Skin elasticity.
C)
Pain scale.
D)
Lung sounds.
E)
Oxygen saturation.
While assessing a patient with degenerative joint disease, the nurse notices Heberden’s nodes, and large prominences on the patient’s fingers that are reddened and painful. What should the nurse do?
A)
Discuss strategies for managing chronic pain with the patient.
B)
Check the patient’s radial pulses and capillary refill time.
C)
Immediately notify the healthcare provider of the finding.
D)
Review the patient’s dietary intake of high-protein foods.
The nurse is caring for a client who reports a sudden, severe facial numbness. The nurse observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. Which intervention should the nurse perform immediately?
A)
Maintain elevated positioning of the dependent joints on the affected side.
B)
Verify prescribed laboratory tests include prothrombin time and platelet count.
C)
Start two large-bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.
D)
Administer aspirin to prevent further clot formation and platelet clumping.

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