Exam Review

Exhibits Chart Reviewed For each statement, click to indicate whether the statement is true or false.

	True	False
Hand washing only needs to be performed when exiting the client’s room.		✓
This client requires contact and droplet precautions.	✓
A gown and gloves should be worn any time there is potential for contact with secretions.	✓
A mask should always be worn when in the client’s room.	✓
This client would require a private room if admitted.	✓

Exhibits What other recommendations could the nurse give to help the patient have better sleep? Select all that apply.
(SATA)
A)
Exercise in the evening.
B)
Watch television in bed to fall asleep.
C)
Take an analgesic before bed.
D)
Avoid alcohol in the evening.
E)
Try to go to bed and awaken at the same time every day.
F)
Avoid naps.
G)
Eat a heavy meal before bed.
Patient Data Exhibits Based on the trending heart rate and pain score, what should the nurse do? Select all that apply.
(SATA)
A)
Assess for sources of pain other than the surgical site.
B)
Change to a behavioral pain scale.
C)
Give a dose of 2.5 mg of morphine.
D)
Refer to social work for drug-seeking behavior.
E)
Bring an opioid reversal agent to the bedside.
F)
Lead the client in guided imagery.
G)
Consult with the surgeon about the pain level.
H)
Helping the client walk around the room.
The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?
A)
Review the client's medical history and admission assessment.
B)
Compare the client's current vital signs to the admission baseline.
C)
Note how frequently doses of analgesics have been administered.
D)
Ask the client to describe the intensity of the pain being experienced.

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Exam Review

Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning?
A)
Using two or three people increases client safety.
B)
The technique is intended to maintain straight spinal alignment.
C)
Turning instead of pulling reduces the likelihood of skin damage.
D)
Working together can decrease the risk of back injury to the nurses.
While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?
A)
Complete the intermittent suction of the nasopharynx.
B)
Apply an oxygen mask over the client's nose and mouth.
C)
Reposition the pulse oximeter clip to obtain a new reading.
D)
Stop suctioning until the pulse oximeter reading is above 95%.
When conducting diet teaching for a client who is on a postoperative clear liquid diet, which foods should the nurse encourage the client to consume? Select all that apply.
(SATA)
A)
Oatmeal, cream of wheat, pureed liquid.
B)
Pureed beans, liquid protein supplements, milkshake.
C)
Pureed carrots, creamed soup, ice cream.
D)
Carbonated drinks, gelatin, broth.
E)
Water, tea, ice chips.
When performing blood pressure measurements to assess for orthostatic hypotension, which action should the nurse implement first?
A)
Record the client's pulse rate and rhythm.
B)
Assist the client to stand at the bedside.
C)
Apply the blood pressure cuff securely.
D)
Position the client supine for a few minutes.

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Exam Review

The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and has the client's toenails? Select all that apply.
(SATA)
A)
Shufling gait.
B)
Urinary incontinence.
C)
Syncope when bending.
D)
Hand tremors.
A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?
A)
Document the site where the medication was given.
B)
Notify the healthcare provider of the allergic response.
C)
Elevate the area and apply light pressure over the site.
D)
Apply a cold pack to the area for twenty minutes.
The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style of shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?
A)
Slip-on rubber shower shoes
B)
Tennis shoes with Velcro
C)
Leather-soled loafers
D)
Rubber-soled slippers
The nurse is entering prescriptions for laboratory work in a client's electronic medical record (EMR) when the system locks up and does not restart. Which action should the nurse take first?
A)
Print the electronic medical record (EMR) from a backup server.
B)
Identify information as a late entry in the record.
C)
Wait for notification that the system has been rebooted.
D)
Notify the information services department of the situation.

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Exam Review

While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, formed, and light brown. Which action should the nurse implement?
A)
Obtain the specimen from the client's current bowel movement.
B)
Contact the healthcare provider before obtaining the specimen.
C)
Wait to obtain the specimen until observable blood is present.
D)
Withhold specimen collection until tarry black stool is observed.
A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. When caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?
A)
Stethoscope.
B)
Bed linens.
C)
Sputum specimen.
D)
Paper mask and gown.
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)
"I'm sorry, but your sibling's medical information is none of your business."
B)
"I can give you those results as soon as I get them back from the lab."
C)
"I can only give medical information to the client with an approved interpreter."
D)
"The healthcare provider will share this information with you."
The nurse has removed a barbiturate capsule from the unit dose wrapper to administer to a client. The client decides to watch a television program and requests not to take the medication. Which action should the nurse implement?
A)
Explain that since the medication is a controlled substance, it must be taken.
B)
Credit the medication back and put it in the client's medication box.
C)
Keep the medication and see if the client will want to take it later.
D)
Have another nurse witness the disposal of the medication into the disposal container.

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Exam Review

An older adult client returns to the clinic for chronic pain management after taking morphine sulfate 25 mg PO every 12 hours. The client reports taking the medication only when the pain was too severe to sleep. Which action should the nurse implement?
A)
Teach the client alternative ways to manage chronic pain.
B)
Instruct the client to take the morphine sulfate every 12 hours as prescribed.
C)
Tell the client to continue taking the morphine sulfate with severe pain.
D)
Explain the risk of drug addiction from long-term pain medications.
The nurse learns that members of the nursing staff are uncomfortable with responding to client family members who are angry. While designing a teaching session to help the staff respond more effectively in these situations, which instructional strategy is best for the nurse to use?
A)
Analogies.
B)
Role-playing.
C)
Return demonstration.
D)
Journaling.
A client who is 2 days postoperative for thoracic surgery is reporting incisional pain 2 hours after receiving pain medication. The client rates the pain as 5 on a pain scale of 0 to 10. After placing a call to the healthcare provider, which action should the nurse implement?
A)
Provide at least 20 minutes of back massage and gentle efleurage.
B)
Instruct the client to use guided imagery and slow rhythmic breathing.
C)
Place a hot water circulation device, such as an aquathermia pad, on the operative site.
D)
Tune to a television show or easy listening music to provide distraction.
After obtaining an oxygen saturation level of 94% for a client with pneumonia who is receiving oxygen via nasal cannula at 3 L/minute, the nurse observes a red mark on the client's right cheek. Which intervention should the nurse implement?
A)
Discontinue the use of the nasal cannula.
B)
Apply lubricant to the cannula tubing.
C)
Place padding around the cannula tubing.
D)
Decrease the flow rate to 1 L/minute.

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Exam Review

When interviewing a client about sexuality/reproductive function, which is the best approach for the nurse to use?
A)
Get the most difficult questions over with first.
B)
Begin with questions that are less sensitive in nature.
C)
Ask questions in a vague, non-specific format.
D)
Share personal values to put the client at ease.
The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?
A)
Heart rate.
B)
Blood pressure.
C)
Temperature.
D)
Respiratory rate.
The mother of a child born with Tetralogy of Fallot asks the nurse, "Why did this happen to my baby? What did I do wrong?" Which response by the nurse is most helpful?
A)
"Is there any particular reason why you think this is your fault?"
B)
"With surgery, your baby should have a full recovery."
C)
"This must be a very difficult time for you."
D)
"You did nothing wrong."
While assisting a client with oral care, the nurse assesses the client's mouth. It is most important for the nurse to take action in response to which finding?
A)
Unpleasant odor of the breath
B)
White patches on the mucosa.
C)
Gumline that has visibly receded.
D)
Discoloration of several teeth.

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