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    Exam Review

    1. While caring for a client with amyotrophic lateral sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?
      A)
      Increasing anxiety.
      B)
      Inappropriate laughter.
      C)
      Asymmetrical weakness.
      D)
      Weakened cough effort.
    2. Patient Data Exhibits Which finding(s) in the client's health record should the nurse recognize places the client at a greater risk of developing gout? Select all that apply.
      (SATA)
      A)
      Obesity
      B)
      Hypertension
      C)
      Drinks beer nightly
      D)
      Daily aspirin
      E)
      Type 2 diabetes mellitus
      F)
      Sleep apnea
      G)
      Ibuprofen for pain
      H)
      Nonsmoker
      I)
      Osteoarthritis
    3. Exhibits Select the 3 dietary choices that are not part of the recommended diet for a client with gout.
      (SATA)
      A)
      Garlic
      B)
      Liver
      C)
      Spinach
      D)
      Oatmeal
      E)
      Chicken
      F)
      Shrimp
      G)
      Lentil
      H)
      Quinoa
      I)
      Oranges
      J)
      Sardines
    4. The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?
      A)
      Eating patterns of dietary intake.
      B)
      Activity level of bowel sounds.
      C)
      Level and amount of physical activity.
      D)
      Color and consistency of feces.
    Page 1 of 13

    Exam Review

    1. A client presents to the emergency department reporting chest pain that is radiating to the left arm, shortness of breath, and diaphoresis. Which medication should the nurse anticipate being prescribed by the healthcare provider?
      A)
      Fentanyl.
      B)
      Hydromorphone.
      C)
      Morphine.
      D)
      Oxycodone.
    2. The nurse assists a client with Parkinson's disease to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. The client tells the nurse of pretending to step over a crack on the floor. How should the nurse respond?
      A)
      Plan to assess the client's cognition after returning to the room.
      B)
      Confirm that this is an effective technique to help with ambulation.
      C)
      Assist the client to a carpeted area to walk more easily.
      D)
      Reorient the client to the present location and circumstances.
    3. The nurse reviews the client history of the presenting illness in the electronic medical record.
      (Highlight — findings requiring follow-up are marked)

      The nurse reviews the client history of the presenting illness in the electronic medical record.

      Click to highlight the two pieces of key subjective data which indicate the client is in need of health interventions.

      A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue inhaler three times, but he just couldn't catch his breath.

      The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.

    4. A client with a renal calculus reports severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority?
      A)
      Acute pain related to renal calculus.
      B)
      Nutritional deficit related to nausea.
      C)
      Impaired renal function related to pain.
      D)
      Risk for aspiration related to vomiting.
    Page 2 of 13

    Exam Review

    1. Patient Data. Exhibits Complete the following sentences by choosing from the lists of corresponding options. Based on history and assessment data, the nurse should prioritize ▾ impaired gas exchange as the priority problem for this client, as evidenced by the client's statement, ▾ "I just can't catch my breath.".
      Dropdown 1:
      Option 1: chronic bronchitis
      Option 2: anxiety disorder
      Option 3: exercise-induced bronchospasm
      Option 4: impaired gas exchange
      Option 5: cardiovascular disease
      Option 6: respiratory infection
      Dropdown 2:
      Option 1: "Episodes like this make me extremely nervous."
      Option 2: "I just can't catch my breath."
      Option 3: "The symptoms seem worse when outdoors and when exercising."
      Option 4: "I've been experiencing chest tightness and a rapid heartbeat."
      Option 5: "My symptoms get worse with physical activity, especially when I jog."
      Option 6: "It's been a couple of months since I had an asthma attack, and I've been feeling unwell recently."
    2. Patient Data Exhibits The nurse has implemented additional needed actions. Click the assessment data which indicates the interventions were successful and which assessment data provides no indication that the interventions were successful. Each column must have at least one, but may have more than one answer selected. Assessment Data: Indicates the Interventions Were Successful/ No Indication that the Interventions Were Successful
      Indicates the Interventions Were SuccessfulNo Indication that the Interventions Were Successful
      Heart Rate 105 beats/minute✓
      Client can now speak in full sentences without pausing.✓
      Lung sounds clear✓
      Respirations 16 breaths/minute✓
      Client reports, “It’s a lot easier to breathe now.”✓
      Blood Pressure 122/84 mmHg✓
    3. Patient Data Exhibits The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.
      A)
      Provide client teaching
      B)
      Apply oxygen via nasal cannula.
      C)
      Ask the client for a list of current medications.
      D)
      Place the client in Trendelenburg position.
      E)
      Notify the healthcare provider of the client's need for intubation.
      F)
      Administer medications as ordered.
    4. Patient Data Exhibits After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.
      A)
      Increase oxygen flow.
      B)
      Administer additional nebulizer treatment as ordered.
      C)
      Raise the head of the bed.
      D)
      Apply a nonrebreather oxygen mask.
      E)
      Provide client incentive spirometer and instruct on use.
      F)
      Take and monitor vital signs.
    Page 3 of 13

    Exam Review

    1. Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome?
      A)
      Husky voice and troubled by hoarseness.
      B)
      Central type obesity, with thin extremities.
      C)
      Warm, soft, moist, salmon colored skin.
      D)
      Visible swelling of the neck, with no pain.
    2. A client who has small cell carcinoma of the lung is admitted with symptoms of syndrome of inappropriate antidiuretic hormone (SIADH). As the client responds to treatment, the client's serum sodium level increases from 120 mEq/L (120 mmol/L) to 125 mEq/L (125 mmol/L). Based on this finding, which intervention should the nurse implement?Reference Range:Sodium [136 to 145 mEq/L (136 to 145 mmol/L)]
      A)
      Assess for increasing fluid volume overload.
      B)
      Withhold next scheduled dose of treatment.
      C)
      Increase neurologic checks to every 2 hours.
      D)
      Maintain the prescribed fluid restriction.
    3. A client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?
      A)
      Palpitations and shortness of breath.
      B)
      Bradycardia and constipation.
      C)
      Muscle cramping and dry, flushed skin.
      D)
      Lethargy and lack of appetite.
    4. The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is most essential in this client's plan of care (POC)
      A)
      Ensure oral suction is available.
      B)
      Provide frequent mouth care.
      C)
      Keep the room at a comfortable temperature.
      D)
      Maintain the client in a semi-Fowler's position.
    Page 4 of 13

    Exam Review

    1. Patient Data Exhibits What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers? Select all that apply.
      A)
      Increase IV fluids to 150 mL/hr
      B)
      Monitor for adverse reaction to antibiotics
      C)
      Repeat CD4+ T-cell count STAT
      D)
      Initiate airborne isolation
      E)
      Administer antiemetic
    2. A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places It over the wound. Which intervention should the nurse implement next?
      A)
      Auscultate the abdomen for bowel sound activity.
      B)
      Bring additional sterile dressing supplies to the room.
      C)
      Obtain a sample of the drainage to send to the laboratory.
      D)
      Prepare the client to return to the operating room.
    3. The nurse is preparing a client for surgery who was admitted from the emergency department following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units SUBQ daily. Which nursing action is a priority?
      A)
      Have the client sign the surgical and transfusion permits.
      B)
      Notify the healthcare provider of the client's medication history.
      C)
      Ensure that the potential for bleeding is explained to the client.
      D)
      Observe the heparin injections sites for signs of bruising.
    4. After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?
      A)
      Right foot pale with sluggish capillary refill.
      B)
      Circumferential edema of right foot.
      C)
      Reports throbbing right leg pain.
      D)
      Increased temperature to lower extremity.
    Page 5 of 13

    Exam Review

    1. A client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling experienced worsens at night. Which client teaching should the nurse provide?
      A)
      Wear braces on both wrists during the night.
      B)
      Notify the healthcare provider as soon as possible.
      C)
      Elevate the hands on two pillows at night.
      D)
      Apply cold compresses for 30 minutes before bedtime.
    2. A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important for the nurse to report which assessment finding to the healthcare provider?
      A)
      Muscle atrophy.
      B)
      Low grade fever.
      C)
      Joint pain.
      D)
      Hematuria.
    3. When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include?
      A)
      Eat a bland diet and avoid spicy foods.
      B)
      Have small frequent meals and sit up for at least two hours after meals.
      C)
      Eat a soft diet with increased intake of milk and milk products.
      D)
      Eat a high fiber diet and increase fluid intake.
    4. The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes vital signs of a heart rate of 140 beats/minute, a respiratory rate of 26 breaths/minute, and a blood pressure of 140/90 mm Hg. Which intervention is most important for the nurse to implement?
      A)
      Administer IV fluid bolus as prescribed by the healthcare provider.
      B)
      Medicate for pain and monitor vital signs according to protocol.
      C)
      Encourage the client to splint the incision with a pillow to cough and deep breathe.
      D)
      Apply oxygen at 10 L/minute via non-rebreather mask and monitor pulse oximeter.
    Page 6 of 13