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    Exam Review

    1. A nurse is preparing to administer lorazepam 0.044 mg/kg IV bolus to a client who weighs 50 kg (110 lb). The amount available is lorazepam injection 4 mg/mL How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
      Correct Answer:0.6 mL
    2. A staff nurse may be exhibiting manifestations of a substance use disorder and is diverting controlled medications while at work. Which of the following actions should the nurse manager take first?
      A)
      Confront the nurse regarding their behavior.
      B)
      Ask the nurse to sign an action plan for behavior improvement.
      C)
      Document the suspicious behavior.
      D)
      Collect data on the nurse's behavior.
    3. A nurse is caring for a client who is 1 day postoperative following a laparoscopic hysterectomy and is reporting nausea and abdominal pain. Which of the following actions should the nurse take first?
      A)
      Encourage the client to ambulate.
      B)
      Insert an NG tube.
      C)
      Auscultate for bowel sounds.
      D)
      Administer an antiemetic.
    4. A nurse is assessing a client who is receiving oxytocin infusion to augment labor. Which of the following findings should the nurse identify as an adverse effect of the medication?
      A)
      Uterine contractions lasting 90 seconds
      B)
      Moderate variability of the FHR
      C)
      Uterine contractions every 2 min
      D)
      FHR 150/min
    Page 1 of 38

    Exam Review

    1. A nurse is assessing a client who is postoperative following abdominal surgery. The client states, "I feel like my incision ripped open.” The nurse notes dehiscence of the incision. Which of the following actions should the nurse take?
      A)
      Extend the client's legs above heart level.
      B)
      Place the client in a low-Fowler's position.
      C)
      Instruct the client to perform the Valsalva maneuver.
      D)
      Apply a dry gauze dressing to the incision.
    2. A nurse is caring for a client who is receiving controlled epidural analgesia infusion. Which of the following nursing actions is appropriate?
      A)
      Cleansing the insertion site daily.
      B)
      Covering the insertion site with a transparent dressing.
      C)
      Administering supplemental opioids as needed.
      D)
      Replacing the infusion tubing every 72 hr.
    3. A nurse is teaching a newly licensed nurse about advance directives for clients who have schizophrenia. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
      A)
      "Clients will need their provider’s approval before signing advance directives."
      B)
      "Clients should contact the court if they wish to change their living will."
      C)
      "Clients can appoint a health care surrogate for when they are unable to make decisions."
      D)
      "Clients must designate a guardian to initiate their advance directives."
    4. A nurse is caring for a client who has a new prescription for lithium carbonate. Prior to administering the first dose, which of the following laboratory values should the nurse evaluate?
      A)
      Arterial blood gases.
      B)
      Total cholesterol.
      C)
      Thyroid hormones.
      D)
      Hemoglobin.
    Page 2 of 38

    Exam Review

    1. A nurse is assessing a client who has delirium due to a febrile illness. Which of the following findings should the nurse expect?
      A)
      Hallucinations.
      B)
      Agnosia.
      C)
      Bradycardia.
      D)
      Aphasia.
    2. A nurse is caring for an infant who is postoperative following the placement of a ventriculoperitoneal shunt for treatment of hydrocephalus. Which of the following findings should the nurse expect?
      A)
      Incisional drainage tests positive for glucose.
      B)
      Irritability.
      C)
      Drowsiness.
      D)
      Decreased head circumference.
    3. A nurse is caring for a client who has a strained knee and a prescription for ice therapy. Which of the following actions should the nurse take?
      A)
      Check the client's skin after 15 min.
      B)
      Apply ice directly on the client's skin.
      C)
      Tell the client ice therapy will increase blood flow.
      D)
      Apply heat after 30 min of ice therapy.
    4. A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing?
      A)
      INR 1.1 (0.8 to 1.1).
      B)
      Hyperemesis.
      C)
      HbA1c 5–6% (4 to 5.9%).
      D)
      Uncontrolled pain.
    Page 3 of 38

    Exam Review

    1. A nurse is assessing a client who is experiencing a hyperglycemic hyperosmolar state. Which of the following findings should the nurse expect? (Select all that apply)
      A)
      Absence of urine ketones.
      B)
      Blood glucose 685 mg/dL (74 to 106 mg/dL).
      C)
      BUN 8 mg/dL (10 to 20 mg/dL).
      D)
      Fruity breath odor.
      E)
      Dehydration.
    2. A nurse in a clinic is providing education to the guardian of a 6-month-old infant on starting solid foods. Which of the following statements should the nurse include in the teaching?
      A)
      "You can add honey to sweeten vegetables if they do not like them."
      B)
      "You can mash canned vegetables instead of purchasing baby food."
      C)
      "Raw carrots are a good snack to provide and can help with teething."
      D)
      "Introduce one new food every 3 to 5 days when starting solid foods."
    3. A nurse is preparing a client for surgery and has just administered the preoperative intravenous anxiolytic. Which of the following actions should the nurse take?
      A)
      Take the client to the bathroom to void.
      B)
      Ask the client to verify the surgical site.
      C)
      Review deep breathing and coughing exercises.
      D)
      Raise the side rails on the bed.
    4. A nurse is delegating care tasks for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel?
      A)
      Inserting a nasogastric tube
      B)
      Converting a continuous IV infusion catheter to an intermittent infusion lock
      C)
      Changing an appliance for a client who has an established ostomy
      D)
      Evaluating the care of a client who is receiving speech therapy following a stroke
    Page 4 of 38

    Exam Review

    1. A nurse is caring for a client who was involved in a motor-vehicle crash. The client reports shortness of breath and chest pain and asks the nurse, "Am I dying?" Which of the following actions should the nurse take first?
      A)
      Inform the client's provider
      B)
      Obtain a pulse oximetry reading
      C)
      Administer pain medication
      D)
      Request a chest x-ray
    2. A nurse is assessing a newborn who is receiving dual phototherapy via overhead lights and a fiberoptic pad for the treatment of hyperbilirubinemia. Which of the following actions should the nurse take?
      A)
      Maintain therapy with the fiber optic pad while having the parent hold the newborn during feedings.
      B)
      Discontinue the overhead lights when the newborn has three seedy stools within 2 hr.
      C)
      Swaddle the newborn in a light blanket before placing them on the fiber optic pad.
      D)
      Determine the positioning of overhead lights by assessing the newborn's axillary temperature.
    3. A nurse in the PACU is caring for a client who has a temperature of 40° C (104° F) and received succinylcholine during surgery. Which of the following medications should the nurse plan to administer to decrease body temperature?
      A)
      Rocuronium
      B)
      Epinephrine
      C)
      Dantrolene
      D)
      Flumazenil
    4. A nurse in the emergency department is caring for a preschooler who has vomiting, irritability, and nuchal rigidity. Which of the following interventions should the nurse anticipate?
      A)
      Provide environmental stimuli.
      B)
      Prepare the child for a lumbar puncture.
      C)
      Obtain daily abdominal girth measurements.
      D)
      Maintain the child in supine position.
    Page 5 of 38

    Exam Review

    1. A nurse is teaching a newly licensed nurse about staff safety issues related to compassion fatigue. Which of the following information should the nurse include in the discussion?
      A)
      Publicly confront coworkers when conflict arises
      B)
      Engage in regular physical exercise
      C)
      Encourage a passive communication style
      D)
      Establish a strong employee code of conduct
    2. A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?
      A)
      Encourage the client to gain 2.3 kg (5 lb) per week.
      B)
      Weigh the client once per week throughout hospitalization.
      C)
      Monitor the client for 1 hr after meals.
      D)
      Allow the client to choose meal times.
    3. A nurse is caring for a client who has acute pulmonary edema. Which of the following is the priority nursing intervention?
      A)
      Administer an IV diuretic
      B)
      Request an analysis of ABGs
      C)
      Initiate oxygen via face mask
      D)
      Insert an indwelling urinary catheter
    4. A nurse is teaching a client who has a prescription for sumatriptan to treat migraines. Which of the following information should the nurse include in the teaching?
      A)
      Start taking sumatriptan at the onset of pain.
      B)
      Elevate the head while lying down to prevent hypotension.
      C)
      Eat a meal before taking sumatriptan.
      D)
      Expect peak analgesia to occur 6 hr after administration.
    Page 6 of 38