NursGuru
    Login/Signup
    Review ModeExam ModePractice Mode

    Exam Review

    1. A male client has right-sided hemiplegia following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit in a wheelchair. To assist the client in transferring from the bed to a wheelchair, which action should the nurse take?
      A)
      Have the client put both arms around the nurse’s neck for support.
      B)
      Place the wheelchair on the client’s left side.
      C)
      Instruct the client to take slow, deep breaths while transferring.
      D)
      Instruct the client to look at his feet.
    2. The electronic medication system alerts the nurse that the medication dose scanned for the client is two times higher than the dose prescribed. Which action should the nurse implement?
      A)
      Withhold the medication until the exact dose is available.
      B)
      Ask the pharmacist if another dose can be dispensed.
      C)
      Report a mismatch of prescribed and available doses.
      D)
      Calculate the dose on hand to match the prescribed dose.
    3. A client diagnosed with primary open-angle glaucoma received a prescription for miotic eye drops. Which instruction should the nurse plan to include in this client’s teaching?
      A)
      Wash your hands after each administration of eye drops.
      B)
      Squeeze your eye closed after administering the drops.
      C)
      Do not allow the dropper bottle to touch the eye.
      D)
      Administer the medication directly on the cornea.
    4. The nurse assists a client who has obstructive sleep apnea (OSA) with evening care. Which intervention is most important for the nurse to implement before leaving the client alone?
      A)
      Lift and lock the side rails in place.
      B)
      Elevate the head of the bed to a 45-degree angle.
      C)
      Apply the client’s positive airway pressure device.
      D)
      Remove dentures or other oral appliance.
    Page 1 of 13

    Exam Review

    1. When administering 0900 medications to four clients, which prescription should the nurse administer first?
      A)
      An antibiotic, to be administered every 6 hours starting at 0900.
      B)
      An analgesic topical patch, to be replaced every 24 hours at 0900.
      C)
      A diuretic, to be administered every 12 hours, at 0900 and 2100.
      D)
      An antianxiety agent, to be administered every day at 0900.
    2. When initiating oxygen per mask to a client who is short of breath, the nurse hears a loud hissing sound after inserting the flowmeter into the wall outlet. Which should the nurse do next?
      A)
      Adjust the flow rate to the prescribed liters per minute.
      B)
      Assess the position of the mask on the client’s face.
      C)
      Release and reinsert the flowmeter in the wall outlet.
      D)
      Attach the flowmeter to a humidification canister.
    3. The nurse is providing teaching to a client who receives a new medication prescription. Which action should the nurse use to evaluate the client’s understanding?
      A)
      Demonstrate how the medication will be taken.
      B)
      Ask the client for any additional questions.
      C)
      Recognize sources of confusion for the client.
      D)
      Inquire about frequency of administration.
    4. An unlicensed assistive personnel (UAP) is assigned to feed a client with meningococcal pneumonia for whom droplet precautions have been implemented. The UAP requests a change in assignment, reporting they have not yet been fitted for an N95 respirator mask. Which action should the nurse take?
      A)
      Send the UAP to be fitted for a particulate filter mask immediately to be able to provide care to this client.
      B)
      Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care.
      C)
      Instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client.
      D)
      Before changing assignments, determine which staff members have fitted particulate filter masks.
    Page 2 of 13

    Exam Review

    1. An adolescent is scheduled to receive a required immunization injection. The client reports being afraid of injections because “shots hurt.” Which action should the nurse take?
      A)
      Offer assurance that this particular immunization is less painful than imagined.
      B)
      Review the importance of receiving the immunization as a protection from disease.
      C)
      Invite the client to use the syringe on a dummy before receiving the immunization.
      D)
      Use distraction to redirect the client’s attention while the nurse gives the injection.
    2. The charge nurse is observing a new nurse administering care during new hire orientation at the hospital. Which activity by the new nurse indicates correct body movement and posture to reduce the risk for injury?
      A)
      Bends at the waist to hang a urinary bedside unit on the bed frame.
      B)
      Picks up an item on the far side of the bed by stretching over the mattress.
      C)
      Pushes the lower drawer of the medication cart closed using one’s hip.
      D)
      Stands erect with knees bent to pull a draw sheet and move the client in bed.
    3. Which assessment data reflects the need for the nurse to include the problem, “Risk for falls,” in a client’s plan of care? Reference Range: Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]
      A)
      Expressed feelings of depression.
      B)
      Stooped posture with a steady gait.
      C)
      Opioid analgesic received one hour ago.
      D)
      Recent serum hemoglobin level of 16 g/dL (160 g/L).
    4. While preparing to obtain a stool specimen for occult blood, the nurse observes that the client’s feces is soft, solid, and light brown. Which action should the nurse implement?
      A)
      Wait to obtain the specimen until observable blood is present.
      B)
      Withhold specimen collection until tarry black stool is observed.
      C)
      Obtain the specimen from the client’s current bowel movement.
      D)
      Contact the healthcare provider before obtaining the specimen.
    Page 3 of 13

    Exam Review

    1. A client, who speaks very little English, is being seen in the emergency department following an automobile accident. The client’s sibling offers to act as an interpreter and asks about the laboratory results. Which response is best for the nurse to provide?
      A)
      The healthcare provider will share this information with you.
      B)
      I’m sorry, but your sibling’s medical information is none of your business.
      C)
      I can give you those results as soon as I get them back from the lab.
      D)
      I can only give medical information to the client with an approved interpreter.
    2. When evaluating the effectiveness of a client’s nursing care, the nurse first reviews the expected outcomes identified in the plan of care. Which action should the nurse take next?
      A)
      Determine if the expected outcomes were realistic.
      B)
      Modify the nursing interventions to achieve the client’s goals.
      C)
      Obtain current client data to compare with expected outcomes.
      D)
      Review related professional standards of care.
    3. The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?
      A)
      Review the pain medications prescribed.
      B)
      Ask the client what is causing the grimacing.
      C)
      Administer PRN oral pain medication.
      D)
      Monitor the client’s nonverbal behavior.
    4. A client is in contact isolation due to a stage IV coccyx wound infected with methicillin-resistant Staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple reentries to the client’s room. In which order should the nurse perform the interventions?
      A)
      Perform tracheostomy care, change coccyx dressing, restart the IV line.
      B)
      Change coccyx dressing, perform tracheostomy care, restart the IV line.
      C)
      Restart the IV line, perform tracheostomy care, change coccyx dressing.
      D)
      Change coccyx dressing, restart the IV line, perform tracheostomy care.
    Page 4 of 13

    Exam Review

    1. A client arrives at the clinic describing concerns to the nurse about mood swings, insomnia, and a lack of focus. Which information should the nurse obtain first?
      A)
      Aggravating factors.
      B)
      Methods to cope with stress.
      C)
      Recent life changes.
      D)
      Onset of symptoms.
    2. The nurse is providing oral care for a client who is unconscious. To safely perform the task, which action should the nurse take?
      A)
      Raise the head of bed to 45 degrees.
      B)
      Don sterile gloves prior to performing oral care.
      C)
      Avoid contact with the roof of the mouth.
      D)
      Place the client in a side-lying position.
    3. A client with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the client’s fluid balance?
      A)
      Blood pressure.
      B)
      Weight.
      C)
      Lung sounds.
      D)
      Turgor.
    4. A client is being admitted to the unit with a varicella zoster virus infection. Which room should the charge nurse assign to the client?
      A)
      A private room with both contact and airborne precautions.
      B)
      A semiprivate room with a roommate who has the same diagnosis and contact precautions.
      C)
      A semiprivate room with a roommate who has the same diagnosis and airborne precautions.
      D)
      A private room with both standard and droplet precautions.
    Page 5 of 13

    Exam Review

    1. The nurse is assisting to lift a client from a wheelchair after surgery. To ensure safe mobility, which action should the nurse take?
      A)
      Bend at the knees to maintain a low center of gravity.
      B)
      Stand with feet 3 inches (7.6 cm) apart for balance.
      C)
      Position self at the back of wheelchair with wheels locked.
      D)
      Ask the client to place hands on the nurse’s shoulders.
    2. The nurse is documenting wound care in a client’s electronic medical record (EMR) when the computer system shuts down. Which action should the nurse implement first?
      A)
      Identify information as late entry in the record.
      B)
      Notify information services department of the situation.
      C)
      Wait for notification that the system has been rebooted.
      D)
      Print electronic medical record (EMR) from backup server.
    3. In planning the turning schedule for a bedfast client, it is most important for the nurse to consider which assessment finding?
      A)
      Warm, dry skin with a fever of 100.0° F (37.8° C).
      B)
      A Braden risk assessment scale rating score of ten.
      C)
      4+ pitting edema of both lower extremities.
      D)
      Hypoactive bowel sounds with infrequent bowel movements.
    4. The nurse is caring for a client who is overweight and easily becomes diaphoretic. In response to this finding, which assessment(s) should the nurse include while assisting the client with personal care? (Select all that apply)
      A)
      Observe skin under the breasts.
      B)
      Palpate mucus membranes for cracks.
      C)
      Assess skin folds of perineal area.
      D)
      Monitor color of nailbeds.
      E)
      Check skin for unusual bruising.
    Page 6 of 13