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    Exam Review

    1. A nurse is caring for a client who has come to the emergency department with frostbite to one of their lower extremities.

      ➢ Which of the following orders by the healthcare provider would the nurse anticipate to treat the client’s frostbite? Select all that apply.

      (SATA)
      A)
      Perform massage on the lower extremity to improve blood flow
      B)
      Apply dry heat with a warming blanket to the lower extremity
      C)
      Administer a tetanus immunization
      D)
      Submerge the lower extremity in a rapid rewarming water bath set at 99⁰ F to 102⁰ F (37⁰ C to 39⁰ C)
      E)
      Report any increasing levels of pain after administering analgesics
      F)
      Assess hourly for development of compartment syndrome

    2. The nurse is assessing a client with suspected heat stroke.

      ➢ Which of the following findings would support a diagnosis of heat stroke? Select all that apply.

      (SATA)
      A)
      decreased renal function
      B)
      electrolyte imbalances
      C)
      tachypnea
      D)
      hypertension
      E)
      pulmonary edema
      F)
      bradycardia

    3. The nurse is teaching a client scheduled for a dual-energy x-ray absorptiometry (DEXA) scan.

      ➢ Which of the following information should the nurse include?

      A)
      "Do not eat or drink 6-8 hours prior to your test."
      B)
      "You will feel flushing as you receive the intravenous contrast."
      C)
      "The scan takes several hours to complete."
      D)
      "Please remove all metallic objects before this exam."

    4. Which of the following accurately summarizes the primary purpose of skin care and hygiene?

      A)
      Maintain skin sterility and prevent infection
      B)
      Prevent bodily odors by eliminating bacteria
      C)
      Protect the body’s first line of defense
      D)
      Provide the client with comfort and well-being
    Page 1 of 38

    Exam Review

    1. The nurse is taking care of a client that is scheduled to undergo a gastric analysis at 8:00 AM tomorrow. Which should be included in the client's plan of care?

      A)
      Instruct the client that she should not eat or drink anything after midnight.
      B)
      Teach the client that in case she feels hungry, she can chew some gum.
      C)
      Instruct the client that she needs to be on bed rest for 2 hours after the procedure.
      D)
      Tell the client that she is allowed to smoke 1 hour prior to surgery.

    2. The nurse who is caring for a post-stroke client suddenly notes that the client has a fixed and dilated pupil. What would be the most appropriate action by the nurse?

      A)
      Reduce environmental stimuli.
      B)
      Reassess after ten minutes.
      C)
      Check the client’s blood pressure.
      D)
      Notify the physician.

    3. A nurse is caring for a client who has Lyme disease.

      ➢ The nurse should request a prescription for which medication from the primary healthcare provider?

      A)
      finasteride
      B)
      doxycycline
      C)
      valacyclovir
      D)
      diphenhydramine

    4. The nurse is performing a head-to-toe assessment for an older adult. Which finding from the integumentary assessment does the nurse recognize as a normal age-related change?

      A)
      Moist skin
      B)
      Increased nail growth
      C)
      Dry, itchy skin
      D)
      Increased skin pigmentation
    Page 2 of 38

    Exam Review

    1. What is the correct documentation of the patient’s peripheral pulse when the finding is that the posterior tibial pulse is weak and thready?

      A)
      Grade C posterior tibial pulse
      B)
      Posterior tibial pulse is Grade B
      C)
      The client’s posterior tibial is 2
      D)
      Posterior tibial pulse is 1

    2. When assessing for dehydration, the nurse should observe for which of the following?

      A)
      Headache and increased urinary output
      B)
      Weight gain and edema
      C)
      Hypertension and decreased urinary output
      D)
      Hypotension, headache, and dry mucous membranes

    3. The nurse is performing discharge education to an older adult diagnosed with cataracts. Which of the following statements indicates effective understanding?

      A)
      “I may have to quit driving until I get the cataracts treated.”
      B)
      "I should spend less time outdoors in the sun and plan more activities at night."
      C)
      "I will need to avoid activities that raise my intraocular pressure, such as bending at the waist."
      D)
      “I will have to be careful since my eyes won’t move together.”

    4. The nurse is caring for a client diagnosed with Reye's syndrome. Which of the following over-the-counter (OTC) medications is Reye’s syndrome associated with?

      A)
      Acetaminophen
      B)
      Ibuprofen
      C)
      Aspirin
      D)
      Brompheniramine/pseudoephedrine
    Page 3 of 38

    Exam Review

    1. The nurse observes a client with a chest tube connected to a closed drainage system ambulating to the bathroom. During ambulation, the chest tube becomes disconnected from the client.

      ➢ Which action should the nurse take?

      A)
      Reinsert the tube after instructing the client to perform the Valsalva maneuver
      B)
      Hold direct pressure over the insertion site with a transparent dressing
      C)
      Apply a sterile occlusive dressing taped on three sides to the insertion site
      D)
      Clamp the chest tube immediately and return the client to bed

    2. The nurse is assessing a 4-year-old client who was sent to the emergency department from urgent care. Assessment reveals tripod positioning, blue lips, mottled skin, inspiratory stridor, and excessive drooling. Vital signs are:

      • Temp: 39 C
      • HR: 188
      • RR: 46
      • O2: 82 %

      What is the priority action for the nurse to take at this time?

      A)
      Keep the child calm and call for emergency airway equipment
      B)
      Obtain IV access
      C)
      Assess the throat for a cherry red epiglottis
      D)
      Place the child on a high flow nasal cannula at 100% FiO2

    3. The nurse is assessing a client with acute cholecystitis. Which of the following physical assessment findings would be expected?

      A)
      Stools that contain blood and mucus
      B)
      Pain with urination
      C)
      Episodic upper abdominal pain
      D)
      Hypoactive bowel sounds

    4. The nurse is caring for a client in the emergency department, reporting a headache and generalized flushing.

      The nurse should request a prescription for which medication? See the exhibit for additional client information.

      Clinical illustration
      A)
      enalapril
      B)
      labetalol
      C)
      amiodarone
      D)
      nitroglycerin
    Page 4 of 38

    Exam Review

    1. The nurse is caring for a client with angle-closure glaucoma.

      ➢ Which prescription should the nurse anticipate from the primary healthcare provider (PHCP)?

      A)
      timolol
      B)
      hydroxyzine
      C)
      phenylephrine
      D)
      imipramine

    2. The nurse cares for a client with the below tracing on the electrocardiogram. The client is unresponsive and without a pulse.

      ➢ Which priority action should the nurse take to convert the rhythm back to normal sinus?

      Clinical illustration

      A)
      Start cardiopulmonary resuscitation (CPR)
      B)
      Perform immediate defibrillation
      C)
      Initiate intravenous (IV) access
      D)
      Review the client's most recent electrolyte levels

    3. The nurse is conducting a staff in-service on managing an acute burn. The nurse should reinforce the utilization of which formula to guide fluid resuscitation?

      A)
      4 mL x kg x Total Body Surface Area (TBSA) burned
      B)
      30 mL/kg
      C)
      0.5 mL/kg/hr
      D)
      0.10 mL/kg/hr

    4. The nurse is preparing to assess a child with cystic fibrosis at the outpatient clinic.

      ➢ The nurse anticipates that the primary healthcare provider (PHCP) will order which routine laboratory test?

      A)
      Blood glucose
      B)
      Total cholesterol
      C)
      24-hour urine
      D)
      Blood cultures
    Page 5 of 38

    Exam Review

    1. The nurse is teaching the parents of a client with cystic fibrosis. Which statement, if made by the parents, would require follow-up?

      A)
      "Chest physiotherapy should be done before giving bronchodilators."
      B)
      "The bronchodilator should be administered before strenuous activity."
      C)
      "My child may have trouble sleeping if the bronchodilator is given at night."
      D)
      "During a respiratory illness, my child should drink more water."

    2. The nurse is counseling a client who has breast cancer. Which tertiary prevention measure should the nurse recommend?

      A)
      Reviewing breast cancer risk factors with the client's family
      B)
      Assessing the unaffected breast for abnormalities
      C)
      Recommending the client's daughter get screened for the BRCA1 or BRCA2 gene
      D)
      Attending a local support group

    3. The charge nurse reviews medical records for clients ready for discharge from the nursing unit. Which client should be recommended for disease management services? A client with

      A)
      congestive heart failure (CHF), who has been admitted three times in the past two months.
      B)
      epilepsy who had one seizure after switching prescribed antiepileptics.
      C)
      diabetes mellitus, with an increase in hemoglobin A1C from 6.7% to 6.9%.
      D)
      schizophrenia being switched from daily dosing to long-acting injectable antipsychotic.

    4. The nurse is caring for a client with pulmonary tuberculosis.

      ➢ Which action should the nurse take?

      A)
      Place a box of disposable respirators inside the client's room.
      B)
      Remove alcohol-based sanitizers from the client's room.
      C)
      Assign the client to a private room with a positive airflow.
      D)
      Remove the portable fan from the client's bedside table.
    Page 6 of 38