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    Exam Review

    1. Twelve hours following a unilateral total knee replacement, a client reports being unable to sleep because of severe incisional pain. What is the best initial nursing action?
      A)
      Instruct the client in use of the prescribed patient-controlled analgesia (PCA) pump.
      B)
      Assist the client in assuming a lateral recumbent position for comfort.
      C)
      Initiate continuous passive motion (CPM) to relieve muscle spasms.
      D)
      Apply ice to the incision for twenty minutes prior to joint flexion exercises.
    2. When turning a male client who has been lying on his back for 2 hours, the nurse notes that the skin over his sacrum is very white. The client is repositioned and when the nurse reassesses the sacrum 2 hours later, the area is bright red. Which intervention should the nurse implement?
      A)
      Apply a warm compress to the sacral area.
      B)
      Wash the area with soap and water.
      C)
      Reassess and turn the client in 30 minutes.
      D)
      Massage the reddened area with lotion.
    3. Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning?
      A)
      The technique is intended to maintain straight spinal alignment.
      B)
      Working together can decrease the risk of back injury to the nurses.
      C)
      Using two or three people increases client safety.
      D)
      Turning instead of pulling reduces the likelihood of skin damage.
    4. 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 1 to 10. After placing a call to the healthcare provider, which action should the nurse implement?
      A)
      Instruct the client to use guided imagery and slow rhythmic breathing.
      B)
      Place a hot water circulation device, such as an Aqua K pad, to the operative site.
      C)
      Tune to a television show or easy listening music to provide distraction.
      D)
      Provide at least 20 minutes of back massage and gentle effleurage.
    Page 1 of 15

    Exam Review

    1. The nurse is caring for a client with obstructive sleep apnea. The nurse should recognize the client is at greater risk for the development of which complication?
      A)
      Hypothyroidism.
      B)
      Hypertension.
      C)
      Peptic ulcer disease.
      D)
      Fibromyalgia.
    2. The healthcare provider prescribes nasogastric tube (NGT) insertion for a client with a postoperative ileus. During insertion, the client begins to gag. Which action should the nurse take?
      A)
      Use firm pressure to pass the tube through the glottis.
      B)
      Have the client tilt head backward to open the passage.
      C)
      Give the client a few sips of water to drink.
      D)
      Remove the tube and attempt reinsertion.
    3. The nurse receives a new prescription to administer oxygen at 3 L/minute via a nasal cannula to maintain an oxygen saturation between 90 and 100% for an adult client. The nurse obtains an oxygen saturation reading of 85% and, after repositioning the oximeter on a different finger, obtains a second reading of 87%. Which action should the nurse take next?
      A)
      Place the client in a Trendelenburg position.
      B)
      Document the second reading in the client record.
      C)
      Securely place the prongs of the cannula in the nostrils.
      D)
      Place the pulse oximeter on the client's earlobe.
    4. The healthcare provider prescribes cefixime oral suspension 200 mg by mouth twice a day for an older adult who has difficulty swallowing pills. The bottle is labeled, "Cefixime for Oral Suspension, USP 100 mg per 5 mL." How many mL should the nurse administer daily? (Enter numerical value only.)
      Correct Answer:20 mL/day
    Page 2 of 15

    Exam Review

    1. An older adult client is admitted to the medical unit following a fall at home. While undressing the client, the nurse observes that the client is wearing an adult diaper and skin breakdown is obvious over the sacral area. Which action should the nurse implement first?
      A)
      Apply a barrier ointment to intact areas that may be exposed to moisture.
      B)
      Determine the size and depth of skin breakdown over the sacral area.
      C)
      Complete a functional assessment of the client's self-care abilities.
      D)
      Establish a toileting schedule to decrease episodes of incontinence.
    2. A client is requesting medicine for pain 30 minutes after receiving morphine sulfate 5 mg intravenously. Which intervention should the nurse implement next?
      A)
      Ask the UAP to offer a backrub to the client.
      B)
      Reassess the client and the level of pain.
      C)
      Tell the client the medication needs more time to work.
      D)
      Encourage the client to focus on taking deep breaths.
    3. The nurse receives a report that a client with an indwelling urinary catheter has an output of 150 mL for the previous 8-hour shift. Which intervention should the nurse implement first?
      A)
      Review the intake and output record.
      B)
      Give the client 8 ounces of water to drink.
      C)
      Notify the healthcare provider.
      D)
      Check the drainage tubing for a kink.
    4. The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?
      A)
      Impaired bed mobility.
      B)
      Fluid volume deficit.
      C)
      Bowel incontinence.
      D)
      Caregiver role strain.
    Page 3 of 15

    Exam Review

    1. 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)
      Stop suctioning until the pulse oximeter reading is above 95%.
      B)
      Reposition the pulse oximeter clip to obtain a new reading.
      C)
      Complete the intermittent suction of the nasopharynx.
      D)
      Apply an oxygen mask over the client's nose and mouth.
    2. The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?
      A)
      Temperature.
      B)
      Blood pressure.
      C)
      Heart rate.
      D)
      Respiratory rate.
    3. The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?
      A)
      Temperature.
      B)
      Blood pressure.
      C)
      Heart rate.
      D)
      Respiratory rate.
    4. The nurse observes a colleague sharing computer credentials with a colleague who is struggling with access to the electronic health record (EHR). Which action should the nurse take?
      A)
      Warn the colleague that their actions are unprofessional.
      B)
      Discuss the action at the next staff meeting.
      C)
      Communicate the observation to the charge nurse.
      D)
      File a detailed incident report with the specific facility.
    Page 4 of 15

    Exam Review

    1. 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)
      "This must be a very difficult time for you."
      B)
      "You did nothing wrong."
      C)
      "With surgery, your baby should have a full recovery."
      D)
      "Is there any particular reason why you think this is your fault?"
    2. The healthcare provider prescribes two doses of an antihypertensive medication for a client. Before administering the second dose, the nurse obtains a blood pressure measurement of 80/50 mm Hg. Which action should the nurse take?
      A)
      Position the client in a lateral lying position.
      B)
      Document the blood pressure and monitor the client.
      C)
      Encourage an increase in oral fluid intake.
      D)
      Hold the medication and notify the healthcare provider.
    3. The nurse is assisting an older adult client who has problems with constipation and reports fear of defecation because of painful hemorrhoids, to establish a regular bowel pattern. Which action should the nurse take?
      A)
      Suggest using a stool softener.
      B)
      Recommend a daily laxative.
      C)
      Obtain a stool specimen.
      D)
      Discuss oral analgesic options.
    4. The nurse is preparing a bladder irrigation for an adult client who has a long-term indwelling urinary catheter. The urine is cloudy with fibrin clots and sediment. Which intervention should the nurse implement?
      A)
      Power flush with 60 mL to remove mucous obstructions.
      B)
      Slowly irrigate catheter with saline using an infusion pump.
      C)
      Clamp the catheter for 30 minutes prior to irrigating.
      D)
      Use a sterile syringe to irrigate with 20 mL normal saline.
    Page 5 of 15

    Exam Review

    1. A female client who is receiving hospice care in her home expresses fear that dying will be painful. Which action should the nurse take first?
      A)
      Include caregiver in discussion of pain relief strategies.
      B)
      Encourage the client to talk about her fear related to pain.
      C)
      Explain that analgesics will be given whenever needed.
      D)
      Provide therapeutic touch along with comfort and support.
    2. The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?
      A)
      Dizziness can occur during cleansing.
      B)
      Foreskin should not be retracted.
      C)
      An erection may occur while providing care.
      D)
      Pubic area should be kept shaved.
    3. The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?
      A)
      Leave the dressing off until consulting with the healthcare provider.
      B)
      Apply a hydrocolloidal gel dressing.
      C)
      Replace the gauze with a transparent dressing.
      D)
      Increase the frequency of the dressing changes.
    4. When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?
      A)
      Determine if the expected outcomes were realistic.
      B)
      Review related professional standards of care.
      C)
      Obtain current client data to compare with expected outcomes.
      D)
      Modify the nursing interventions to achieve the client's goals.
    Page 6 of 15