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    Exam Review

    1. The nurse is teaching a client how to self-administer low-molecular-weight heparin subcutaneously. Which instruction should the nurse include?
      A)
      Massage the injection site to increase absorption.
      B)
      Rotate injections between the abdomen and gluteal areas.
      C)
      Expel the air in the prefilled syringe prior to injection.
      D)
      Inject in abdominal area at least 2 inches from the umbilicus.
    2. Patient Data Exhibits Based on the trending heart rate and pain score, what should the nurse do? Select all that apply.
      (SATA)
      A)
      Lead the client in guided imagery
      B)
      Give a dose of 2.5 mg of Morphine
      C)
      Assist the client to walk around the room
      D)
      Assess for sources of pain other than the surgical site
      E)
      Consult with the surgeon about the pain level
    3. The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?
      A)
      Switch to a non-rebreather mask.
      B)
      Remove the nasal cannula.
      C)
      Increase the oxygen to 3 L/minute.
      D)
      Verify the placement of the pulse oximeter.
    4. Which assessment is most important for the nurse to perform prior to the application of a heating pad?
      A)
      Limitations to range of motion.
      B)
      Muscle strength and tone.
      C)
      Degree of neurosensory impairment.
      D)
      Presence of rebound phenomenon.
    Page 1 of 11

    Exam Review

    1. After an intravenous antibiotic is started, the nurse determines that the medication is not prescribed for the client and stops the infusion. Which action should the nurse implement next?
      A)
      Notify the healthcare provider.
      B)
      Document the event on the chart.
      C)
      Complete an incident report.
      D)
      Inform the nurse on the next shift.
    2. A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?
      A)
      Irrigate the nasogastric tube with water.
      B)
      Review the advance directive document.
      C)
      Elevate the head of bed 45 degrees.
      D)
      Perform oropharyngeal suctioning.
    3. A client with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage?
      A)
      Regular exercise.
      B)
      Stress reduction.
      C)
      Smoking cessation.
      D)
      Low-fat diet.
    4. The nurse observes a decrease in a client's level of consciousness. Which vital sign should the nurse obtain first?
      A)
      Blood pressure.
      B)
      Temperature.
      C)
      Respiratory rate.
      D)
      Pulse rate.
    Page 2 of 11

    Exam Review

    1. Patient Data Exhibits Review H and P and nurse's notes. Identify from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
      ✓Provide skin care
      ✓Place an incontinence containment product under the client
      ✓Overflow urinary incontinence
      ✓Intake and output
      ✓Post-void residual
      Actions to Take
      ✕Create a toilet training program
      ✕Place an indwelling catheter
      ✕Teach the client to use mobility aids
      ✓Provide skin care
      ✓Place an incontinence containment product under the client
      Potential Conditions
      ✕Reflex urinary incontinence
      ✕Urge incontinence
      ✕Functional incontinence
      ✓Overflow urinary incontinence
      ✕Place an incontinence containment product under the client
      Parameters to Monitor
      ✓Intake and output
      ✕Skin integrity
      ✕Blood pressure
      ✕Blood glucose
      ✓Post-void residual
    2. A client who had surgery 3 days ago is sitting with head of bed at 75 degrees and requests to be repositioned. Which instruction is most important for the nurse to provide to the unlicensed assistive personnel (UAP)?
      A)
      Have the client hold a pillow over the abdomen to cough and deep breathe.
      B)
      Encourage the client to eat all of the meals that are sent.
      C)
      Offer fruit juice at least twice during both the day and evening shifts.
      D)
      Lower the bed prior to helping the client to move up in bed.
    3. The nurse is teaching a client how to self-administer low-molecular-weight heparin subcutaneously. Which instruction should the nurse include?
      A)
      Massage the injection site to increase absorption.
      B)
      Rotate injections between the abdomen and gluteal areas.
      C)
      Expel the air in the prefilled syringe prior to injection.
      D)
      Inject in abdominal area at least 2 inches from the umbilicus.
    4. A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client's parents arrive and are asking questions about the client's laboratory results. Which response is best for the nurse to provide?
      A)
      "I'm sorry, but your child'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)
      "The healthcare provider will share this information with you."
      D)
      "I can only give medical information to your child because they are legally an adult."
    Page 3 of 11

    Exam Review

    1. The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the client’s foot in a basin of warm water placed on the bed. Which action should the nurse take?
      A)
      Remind the UAP to dry between the client’s toes completely.
      B)
      Advise the UAP that this procedure is damaging to the skin.
      C)
      Add skin cream to the basin of water while the foot is soaking.
      D)
      Remove the basin of water from the client’s bed immediately.
    2. While assessing a client’s blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm calibration. Upon release of the air valve, the nurse immediately hears loud Korotkoff sounds. Which action should the nurse implement next?
      A)
      Release the air and reinflate the cuff to 30 mm Hg above the client’s previous systolic reading.
      B)
      Continue the blood pressure assessment until the last Korotkoff sound is heard.
      C)
      Reposition the stethoscope in the antecubital fossa over the palpable brachial pulse point.
      D)
      Inflate the cuff quickly to a higher mm Hg reading than the previously auscultated systolic sound.
    3. After administering oxycodone to a client one hour ago, the client is reporting severe pain. Which intervention should the nurse implement next?
      A)
      Reassess the client and the level of pain.
      B)
      Tell the client the medication needs more time to work.
      C)
      Ask the UAP to offer a backrub to the client.
      D)
      Encourage the client to focus on taking deep breaths.
    4. The nurse observes the unlicensed assistive personnel (UAP) securing a client’s wrist restraints to the bedside rails. Which action is most important for the nurse to implement?
      A)
      Complete an adverse occurrence/incident report.
      B)
      Ensure that the restraints are not too tight.
      C)
      Demonstrate proper securing of the restraints.
      D)
      Initiate the facility’s restraint flow sheet.
    Page 4 of 11

    Exam Review

    1. The nurse plans to administer naloxone 1 mg. The label of the 10 mL vial indicates that the drug concentration is 0.4 mg/mL. How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)
    2. The nurse is assessing a client in the clinic who is frightened and does not understand English. Which intervention should the nurse implement first?
      A)
      Request a family member to remain with the client.
      B)
      Ask for the support of one of the client’s friends.
      C)
      Use drawings that are universal for all cultures.
      D)
      Obtain a staff member who is a bilingual interpreter.
    3. A male client with a nasogastric tube connected to low intermittent suction tells the nurse that his mouth is very dry. Which action should the nurse implement?
      A)
      Instill 50 mL of normal saline solution into the tube and clamp the tube for one hour.
      B)
      Turn the suction off while allowing the client to rinse his mouth with cool water.
      C)
      Provide oral sponge toothettes so the client can cleanse and moisten his mouth.
      D)
      Teach the client that the oral mucosa must remain dry to prevent aspiration.
    4. The nurse administers morphine to a client for chest pain who also has obstructive sleep apnea (OSA). 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)
      Apply the client's positive airway pressure device.
      C)
      Elevate the head of the bed to a 45-degree angle.
      D)
      Remove dentures or other oral appliances.
    Page 5 of 11

    Exam Review

    1. Prior to initiating digital removal of a fecal impaction, it is most important for the nurse to perform which client assessment?
      A)
      Abdominal girth.
      B)
      Bowel sounds.
      C)
      Vital signs.
      D)
      Breath sounds.
    2. The nurse identifies several nursing problems for a client with paraplegia who has been having fecal incontinence and diarrhea. The client's parent is the primary caregiver. In planning care, the nurse should determine which problem is the highest priority?
      A)
      Fluid volume deficit.
      B)
      Bowel incontinence.
      C)
      Caregiver role strain.
      D)
      Impaired bed mobility.
    3. A client who is on complete bedrest frequently calls the nurse for the bedpan to urinate. Which action should the nurse take to evaluate the client for urinary retention?
      A)
      Palpate the suprapubic region for distention.
      B)
      Scan the client's bladder after voiding.
      C)
      Review the chart for number of voids over last 24 hours.
      D)
      Evaluate the client for urinary incontinence.
    4. The nurse observes that there are reddened areas on the cheekbones of a client receiving oxygen per nasal cannula at 3 L/minute, and the client's oxygen saturation level is 92%. Which intervention would the nurse implement?
      A)
      Decrease the flow rate to 1 L/minute.
      B)
      Place padding around the cannula tubing.
      C)
      Apply lubricant to the cannula tubing.
      D)
      Discontinue the use of the nasal cannula.
    Page 6 of 11