NursGuru

    Exam Review

    1. Following a motorcycle collision, a young adult client's fractured left tibia was surgically repaired and a long leg cast was applied. For the past two days, the client has been ambulating with the use of crutches. The client reports increased weakness in both forearms. Which action should the nurse take?
      A)
      Watch client while crutch walking.
      B)
      Measure the blood pressure in both arms.
      C)
      Encourage additional rest periods.
      D)
      Demonstrate arm strengthening exercises.
    2. A client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation extends above the ankle area. The client receives prescriptions for colchicine and indomethacin. Which instruction should the nurse include in the discharge teaching?
      A)
      Support joints in an extended position while resting.
      B)
      Eat high protein foods to achieve ideal body weight.
      C)
      Avoid the consumption of wine, beer, and coffee.
      D)
      Limit use of mobility equipment to avoid muscle atrophy.
    3. A client arrives to the emergency department (ED) following a motor vehicle collision. The nurse observes the client experiencing increasing dyspnea and notes absent breath sounds on the left side. Which procedure should the nurse prepare the client for?
      A)
      Endotracheal intubation.
      B)
      Bronchoscopy.
      C)
      Pulmonary function test.
      D)
      Chest tube insertion.
    4. The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which activity should the nurse assign to the PN?
      A)
      Administer medications by piggyback infusion.
      B)
      Initiate teaching for client care after discharge.
      C)
      Determine the need for urinary catheterizations.
      D)
      Complete comprehensive assessments.

    Exam Review

    1. After a week of bedrest, a client is being assisted to a chair for the first time. The nurse raises the head of the bed and moves the client to a sitting position. Which action should the nurse implement?
      A)
      Place the chair by the bed.
      B)
      Support the client when rising.
      C)
      Offer a pair of nonskid socks.
      D)
      Determine how the client feels.
    2. An unlicensed assistive personnel(UAP) is assigned to feed a client who has received a prescription to institute droplet precautions for a bacterial meningitis infection. The UAP requests a change in assignment, reporting having not yet been fitted for a particulate filter mask. Which action should the nurse take?
      A)
      Before changing assignments, determine which staff members have fitted particulate filter masks.
      B)
      Advise the UAP to wear a standard face mask to obtain 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 to be able to provide care for the assigned client.
      D)
      Send the UAP to be fitted for a particulate filter mask immediately so the UAP can provide care to this client.
    3. While interviewing an older adult client, the nurse observes that the client's hands tremble uncontrollably while reaching for a glass of water. How should the nurse document this finding?
      A)
      Intention tremor.
      B)
      Transient ischemic attack.
      C)
      Muscle flaccidity.
      D)
      Sensory dysfunction.
    4. The nurse wants to use the SPICES framework with the client. Choose the most likely options for the information missing from the statements(s) by selecting from the list of options provided. The SPICES framework is a ▾ Guidethat nurses can use to identify ▾ Early signs of illnessin older adults.
      Dropdown 1:
      Option 1: Guide
      Option 2: Diagnostic test
      Option 3: Therapeutic protocol
      Option 4: Surgical tool
      Dropdown 2:
      Option 1: Alzheimer's disease
      Option 2: Early signs of illness
      Option 3: Dehydration
      Option 4: Musculoskeletal abnormalities

    Exam Review

    1. Which other assessment technique(s) can the nurse use to identify the potential source of the client's new onset confusion and decreased appetite? Select all that apply.
      (SATA)
      A)
      Perform a 12-lead electrocardiogram
      B)
      Collect a sputum and urine culture
      C)
      Ask about the client's last bowel movement
      D)
      Measure the client's vital signs
      E)
      Ask to see the client's list of home medications
      F)
      Measure the client's abdominal circumference
      G)
      Have the client ambulate across the room
    2. Review the table below showing risk factors for the client. Highlight the interventions that are appropriate and safe for each risk factor. Risk Factor Intervention Risk for infection Have the client wear a surgical mask Discontinue metformin Encourage the client to use good hand hygiene Risk for skin breakdown Hold the client's metformin Use an indwelling urinary catheter Assess the skin beneath the nasal cannula and blood pressure cuff regularly Risk for falls Provide appropriate footwear Dim the lights in the room Apply restraints
      (Highlight — findings requiring follow-up are marked)

      Review the table below showing risk factors for the client. Highlight the interventions that are appropriate and safe for each risk factor.

      Risk Factor

      Intervention

      Risk for infection

      Have the client wear a surgical mask

      Discontinue metformin

      Encourage the client to use good hand hygiene

      Risk for skin breakdown

      Hold the client's metformin

      Use an indwelling urinary catheter

      Assess the skin beneath the nasal cannula and blood pressure cuff regularly

      Risk for falls

      Provide appropriate footwear

      Dim the lights in the room

      Apply restraints

    3. The nurse reviewed the chest x-ray results indicating pneumonia. Based on the interaction that they had with the client at noon, the nurse is concerned. Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. The nurse determines the client is likely experiencingdropdown. To address this condition the nurse willdropdown. The nurse will also monitordropdown to assess the client's progress.
    4. Choose the most likely options for the information missing from the statement by selecting from the list of options provided. Based on the weaning of the oxygen, the client's hypoxia was likely caused bydropdown and increased metabolic demand due todropdown.

    Exam Review

    1. A client with a prescription for morphine sulfate 2 mg IV every 4 hours PRN for pain reports the pain is a 10 on a 0 to 10 scale one hour after receiving the last administration. Which intervention should the nurse implement?
      A)
      Administer an additional dose of morphine sulfate 2 mg IV.
      B)
      Review the medical record for additional pain medication prescriptions.
      C)
      Contact the healthcare provider about the frequency of pain medication.
      D)
      Encourage the client to allow more time for the medication to work.
    2. A client who is sexually active presents to the clinic for an annual physical exam. Which information is a priority for the nurse to provide?
      A)
      Advise alcohol intake may lead to risky behaviors.
      B)
      Recommend consistent use of latex condoms,
      C)
      Discuss the purpose of annual infection screening.
      D)
      State infections may have no initial symptoms.
    3. When conducting a physical examination, the nurse is assessing a client's abdomen and identifies a centrally localized distention that is pulsating. This finding should direct the nurse to consider which pathology?
      A)
      Appendicitis.
      B)
      Hernia.
      C)
      Tympany.
      D)
      Aneurysm.
    4. A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider (HCP)?
      A)
      Delayed painful rash with urticaria.
      B)
      Arthritic joint changes and chronic pain.
      C)
      Lower back pain and hypotension.
      D)
      Acute rhinitis and nasal stuffiness.

    Exam Review

    1. A client with heart failure (HF), who is taking furosemide, reports having muscle cramps and weakness in the lower extremities. Which action should the nurse implement?
      A)
      Stretch the foot into dorsiflexion.
      B)
      Encourage the use of salt with meals.
      C)
      Restrict potassium rich foods.
      D)
      Collect blood for serum electrolytes.
    2. A male client who had abdominal surgery 5 days ago, and hospitalized because of a surgical wound infection, tells the nurse that he feels like his insides just spilled out when he coughed. Which action should the nurse take first?
      A)
      Obtain sterile towels soaked in saline.
      B)
      Assure the client that such feelings occur with wound infections.
      C)
      Notify the healthcare provider (HCP).
      D)
      Visualize the abdominal incision.
    3. The RN charge nurse of a 24-bed medical unit is making shift assignments for 2 experienced registered nurses (RN), 1 graduate registered nurse, 1 practical nurse (PN), and 2 unlicensed assistive personnel (UAP). Which client should the nurse assign to the most experienced RN?
      A)
      The 28-year-old who is being prepared for a laparoscopic cholecystectomy this morning.
      B)
      The 72-year-old admitted with urosepsis who is being transferred to a skilled unit today.
      C)
      The 48-year-old with advanced cancer who has requested not to be resuscitated.
      D)
      The 36-year-old admitted with angina who has a history of coronary artery disease.
    4. A client who weighs 176 pounds receives a prescription for filgrastim 5 mcg/kg/daily subcutaneously for 14 days. The medication is available in a 300 mcg/mL vial. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

    Exam Review

    1. The nurse is caring for a client who is receiving gentamicin IV. Which adverse effect is most important for the nurse to report to the healthcare provider (HCP)?
      A)
      Nausea.
      B)
      Oliguria.
      C)
      Vertigo.
      D)
      Headache.
    2. A 5-year-old boy with mumps is being transferred to the pediatric unit. Which nursing intervention is most important for the nurse to implement?
      A)
      Place an isolation cart outside of the room to initiate droplet precautions.
      B)
      Assign the child to a room close to the nurse's station.
      C)
      Schedule bedside play time with the occupational therapist.
      D)
      Instruct the child's parents about the need for transmission precautions.
    3. After a seven day treatment with an IV antibiotic, the healthcare provider discharges a client from the hospital and writes a prescription for an oral antibiotic. While providing discharge instructions, the nurse notes that the dosage for the oral antibiotic is significantly higher than the IV antibiotic. Which resource should the nurse use first in resolving the situation?
      A)
      Nursing unit charge nurse.
      B)
      Healthcare provider.
      C)
      Hospital pharmacist.
      D)
      Medication reference guide.
    4. An older adult client who resides in a long-term care facility is incontinent of urine and has a stage II pressure injury on the left heel. When the client becomes confused, which assessment is most important for the nurse to obtain?
      A)
      Amount of serous drainage from left heel.
      B)
      White blood cell count (WBC).
      C)
      Urinary output for past six hours.
      D)
      24-hour medication history.