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    Exam Review

    1. The nurse is teaching the parents of a toddler about toilet training.

      ➢ Which of the following statements would be most important for the nurse to make to the parent?

      A)
      "Praise your child for cooperative behavior."
      B)
      "Dress your child in easily removed clothing."
      C)
      "If a potty chair is not available, have the child sit facing the toilet tank."
      D)
      "Let the child observe the excreta being flushed down the toilet."

    2. A 52-year-old client comes to the clinic and tells the nurse: “I can’t believe it! I’ve been having hot flashes the last few months and thought I was going into menopause, but I guess I’m pregnant!” The client then shows her the positive pregnancy test kit. What is the most appropriate response of the nurse?

      A)
      “Wow! That’s good news! Let’s celebrate!”
      B)
      “Really? How can that be? You’re too old.”
      C)
      “That sounds exciting, but we will have to confirm with an ultrasound. People undergoing menopause tend to have a false-positive pregnancy test.”
      D)
      “Let’s do another urine pregnancy test and check if it’s still positive.”

    3. The nurse is providing education about ways of acquiring toxic shock syndrome (TSS).

      ➢ The nurse would include the following clients are at risk of TSS, except:

      A)
      A teenage client using an absorbent tampon.
      B)
      A 29-year-old woman using a cervical cap.
      C)
      A 31-year-old woman using a diaphragm.
      D)
      A 35-year-old woman using oral contraceptives.

    4. A 12-year-old child is scheduled for an appendectomy. The child’s mother has already signed the consent form and the child is about to be wheeled by the nurse to the operating room when her father arrives. It is made known to the nurse that the child’s parents are divorced and have joint legal custody. Which action by the nurse is most appropriate?

      A)
      Have the father sign a new consent form.
      B)
      Cancel the operation.
      C)
      Proceed with the child’s operation.
      D)
      Notify the physician.
    Page 1 of 38

    Exam Review

    1. The nurse is reviewing the laboratory results of a client scheduled for surgery.

      ➢ Which of the following should be reported to the primary health care provider (PHCP)?

      A)
      Glycosylated hemoglobin (HbA1c) of 7.2% [5.7-6.4%]
      B)
      International Normalized Ratio (INR) of 3.5 [0.9-1.2 seconds]
      C)
      Hematocrit (Hct) of 42% [Male: 42-52% Female: 37-47%]
      D)
      Blood urea nitrogen (BUN) level of 5 [10-20 mg/dL]

    2. The nurse is performing a continuing education seminar. It would be correct for the nurse to identify which factor increases the older adult's risk for illness?

      A)
      Increased lymph tissue
      B)
      Increased autoimmune responses
      C)
      Increased circulation of lymphocytes
      D)
      Increased T and B cell production

    3. The nurse is caring for an older adult with advanced dementia. The client asks about her deceased sister, "When will my sister come to visit me this afternoon?" Which is the best response from the nurse?

      A)
      "This is so sad. I’m sorry to tell you but your sister died last year.”
      B)
      “She won’t be coming to visit today.”
      C)
      “I understand you want her to visit you. Where did you and your sister grow up?”
      D)
      “Wait and see if she comes to visit today.”

    4. The charge nurse is making room assignments for assigned clients. The charge nurse has one private room remaining, the nurse should assign the private room to the client admitted with

      A)
      epilepsy, who had a tonic-clonic seizure two hours ago.
      B)
      an indwelling urinary catheter and has proteus mirabilis in the urine.
      C)
      viral meningitis and has a fever.
      D)
      clostridium difficile who is incontinent of stool.
    Page 2 of 38

    Exam Review

    1. The nurse is caring for a 26-year-old patient who cannot meet their nutritional needs by mouth. The interdisciplinary team decided inserting an NG tube for enteral feedings would be best. After inserting the tube, the nurse knows which of the following is the most accurate way to verify the placement of the tube?

      A)
      Aspiration of stomach contents
      B)
      pH verification of the aspirate
      C)
      Injecting air into the tube and then auscultating the left upper quadrant (LUQ)
      D)
      Visualization on an X-ray

    2. The nurse is caring for a 16-year-old client with cystic fibrosis. The client develops a temperature of 101.2° F (38.4° C). The nurse should obtain a prescription for

      A)
      azithromycin.
      B)
      pancrelipase.
      C)
      multivitamin.
      D)
      albuterol.

    3. The nurse is working with an advocacy group to raise awareness about cystic fibrosis. Which statement best explains the condition?

      A)
      “It is an inherited disease that causes inflammation and hypersensitivity of the airway.”
      B)
      “It is an infectious disease causing inflammation and fluid accumulation in the alveoli of the lungs.”
      C)
      “It is an inherited disease causing excessive, thick mucus to build up in the body and cause blockages.”
      D)
      “It is an acquired disease that causes inflammation and swelling of the epiglottis.”

    4. The nurse is caring for a client with a jejunostomy tube receiving intermittent enteral feedings.

      ➢ Which intervention would reduce this client's aspiration risk?

      A)
      Flush tubing with 10 mL water after feeding is completed
      B)
      Assess the client's gag reflex prior to feeding
      C)
      Assess blood glucose every 6 hours
      D)
      Position the client in semi-Fowler’s during and after the feeding
    Page 3 of 38

    Exam Review

    1. The nurse is assessing a client who just returned from surgery. The nurse checks preoperative vital signs at 0830 to compare them with the current vital signs at 1030. What action should the nurse take? See the image below.

      Clinical illustration

      A)
      Assess the surgical wound
      B)
      Collect blood cultures
      C)
      Administer oxygen at 2 L/minute
      D)
      Encourage by-mouth (PO) fluids

    2. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD).

      ➢ Based on the vital signs, which of the following actions should the nurse take? Click the exhibit button for additional client information.

      Clinical illustration
      A)
      Administer acetaminophen (APAP)
      B)
      Provide the client with warm blankets
      C)
      Apply oxygen at 2 liters via nasal cannula
      D)
      Obtain an arterial blood gas (ABG)

    3. The nurse is caring for a client newly diagnosed with diabetes mellitus (type one).

      ➢ It would be essential to educate the client to

      A)
      check their hemoglobin A1C level every three months.
      B)
      rotate injection sites for insulin administration.
      C)
      examine their feet with a mirror daily.
      D)
      recognize the symptoms of hypoglycemia.

    4. The nurse is developing a self-management teaching plan for a client with low back pain.

      ➢ Which of the following should the nurse include?

      A)
      "Avoid bending at the waist and lifting heavy objects."
      B)
      "Weight-bearing exercises are recommended."
      C)
      "Wear shoes with a higher heel."
      D)
      "Lay on your stomach four times daily and flex your legs."
    Page 4 of 38

    Exam Review

    1. The nurse is reviewing the assessment data for a client with acute glomerulonephritis (AGN). Which of the following would be an expected finding?

      A)
      Ketonuria
      B)
      Hematuria
      C)
      Polyuria
      D)
      Glycosuria

    2. The nurse is caring for a client who has been prescribed depot medroxyprogesterone acetate [DMPA].

      ➢ Which of the following statements by the client would require further teaching?

      A)
      “I will need another injection in 8 weeks.”
      B)
      “I may gain weight while on this medication.”
      C)
      "I can expect some breakthrough bleeding while on this medication."
      D)
      “I should increase my weight-bearing exercises.”

    3. The nurse reviews the assessment data for a child with acute glomerulonephritis (AGN).

      ➢ Which of the following assessment findings would be expected?

      A)
      Urine specific gravity of 1.004 [1.005-1.030]
      B)
      Proteinuria
      C)
      Urinary incontinence
      D)
      Hypotension

    4. The nurse is planning care for a client experiencing a hyperglycemic hyperosmolar state (HHS).

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

      A)
      Infusion intravenous fluids
      B)
      Glargine insulin
      C)
      Sodium polystyrene
      D)
      Sodium bicarbonate
    Page 5 of 38

    Exam Review

    1. The nurse in the emergency department (ED) is caring for a client admitted with diabetic ketoacidosis (DKA). Which clinical data requires immediate follow-up?

      A)
      Respiratory rate (RR) 23/minute
      B)
      Capillary blood glucose 319 mg/dL (17.70 mmol/L) [70-110 mg/dL, 4.0–11.0 mmol/L]
      C)
      Mean arterial pressure (MAP) 51 mm Hg
      D)
      PaO2 90 mm Hg [80-100mm Hg]

    2. The home health nurse is assessing a client in their home with suspected carbon monoxide poisoning.

      ➢ The nurse should take which priority action?

      A)
      Move the client outdoors
      B)
      Notify the primary healthcare provider (PHCP)
      C)
      Auscultate the client's lung sounds
      D)
      Assess the client's pulse oximetry

    3. The nurse is caring for a postoperative client who is ordered to use an incentive spirometer. The nurse understands that this device will help prevent which complication?

      A)
      venous thromboembolism
      B)
      obstructive sleep apnea
      C)
      hypostatic pneumonia
      D)
      aspiration pneumonia

    4. The emergency department (ED) nurse is triaging clients in the ED. It would be appropriate for the nurse to triage which client as nonurgent? A client Select all that apply.

      A)
      with a localized abscess on the right leg.
      B)
      reporting that they have chest pressure.
      C)
      with nausea, vomiting, and painful urination.
      D)
      requesting a refill of their prescribed antidepressant.
      E)
      with a single laceration to the left hand.
    Page 6 of 38