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    Exam Review

    1. The nurse is caring for an infant following a cheiloplasty.

      ➢ Which supply item should the nurse have at the bedside following this procedure?

      A)
      Nasogastric tube (NGT)
      B)
      Bottle of sterile water
      C)
      Suction equipment
      D)
      Tracheostomy

    2. The nurse is assessing a client receiving mechanical ventilation. Which clinical data is most important to review before weaning the client off the ventilator?

      A)
      Chest x-ray
      B)
      Sputum culture
      C)
      Lung sounds
      D)
      Arterial blood gas (ABG)

    3. The nurse is assessing a client with carbon monoxide (CO) poisoning. Which of the following would be an expected finding?

      A)
      Decreased pulse oximetry (SpO2)
      B)
      Hyperarousal
      C)
      Bradycardia
      D)
      Headache

    4. The nurse is caring for a client taking prescribed clozapine. Which clinical data should the nurse monitor? Select all that apply.

      (SATA)
      A)
      Weight
      B)
      Complete blood count (CBC)
      C)
      Urine specific gravity (USG)
      D)
      Fasting blood glucose
      E)
      Total cholesterol
    Page 1 of 38

    Exam Review

    1. The nurse is preparing for a client to undergo a closed reduction of the shoulder with moderate (procedural) sedation.

      ➢ The nurse plans on obtaining which clinical data during the procedure? Select all that apply.

      (SATA)
      A)
      Blood pressure
      B)
      End-tidal carbon dioxide [ETCO2] level
      C)
      Respiratory rate
      D)
      Blood glucose
      E)
      Oxygen saturation

    2. The nurse is teaching a client who is pregnant about how to increase the fiber in her diet. It would be appropriate for the nurse to recommend which foods? Select all that apply. 

      (SATA)
      A)
      Bran muffin
      B)
      Kidney beans
      C)
      Brown rice
      D)
      Whole wheat pasta
      E)
      Corn
      F)
      French fries

    3. The nurse is developing a plan of care for a client admitted to the mental health unit with significant paranoia.

      ➢ Which of the following should the nurse include in the client's plan of care? Select all that apply. 

      (SATA)
      A)
      Plan competitive activities with other clients.
      B)
      Maintain consistent caregivers.
      C)
      Establish a rapport using therapeutic touch.
      D)
      Involve the client in decision-making.
      E)
      Develop a plan of care that is unstructured.
      F)
      Immediately enroll the client in group therapy.

    4. The nurse is developing a plan of care for a client with an impairment to the hypoglossal cranial nerve. Which of the following should the nurse include in the client’s plan of care?

      Select all that apply.

      (SATA)
      A)
      Observe the client during meals
      B)
      Keep suction at the bedside
      C)
      Provide large print education materials
      D)
      Teach the client to scan the room
      E)
      Alternate the use of an eye patch
    Page 2 of 38

    Exam Review

    1. The nurse is caring for an assigned client. Which prescription requires clarification with the primary healthcare provider (PHCP) based on the laboratory data? See the image below. Select all that apply.

      Clinical illustration

      (SATA)
      A
      Option A
      A)
      furosemide
      B)
      vancomycin
      C)
      ibuprofen
      D)
      citalopram
      E)
      enalapril

    2. The nurse is caring for a client with Huntington’s disease. Which of the following assessment findings would be expected?

      Select all that apply.

      (SATA)
      A)
      Halitosis
      B)
      Chorea
      C)
      Hallucinations
      D)
      Hematemesis
      E)
      Weight loss

    3. The nurse is discussing infection control practices in the nursing unit.

      ➢ Which client requires droplet precautions? A client with Select all that apply. 

      A)
      diagnosed with rubella.
      B)
      a new diagnosis of pharyngeal diphtheria.
      C)
      receiving chemotherapy via an implanted port.
      D)
      pulmonary tuberculosis receiving nebulizer treatments.
      E)
      a skin abscess that tested positive for Klebsiella.
      F)
      Haemophilus influenzae, type b

    4. The nurse is caring for several infants in the NICU. Which of the following signs would the nurse recognize as indicative of heart failure in an infant? Select all that apply.

      A)
      Sudden weight loss
      B)
      Tachycardia
      C)
      Diaphoresis
      D)
      Fatigue
      E)
      Bradypnea
    Page 3 of 38

    Exam Review

    1. The nurse is caring for a client with a nasogastric tube (NGT) connected to suction.

      ➢ Which of the following actions should the nurse perform when irrigating an NGT with water? Select all that apply.

      A)
      Draw up 30 mL of warm water into the syringe.
      B)
      Unclamp the suction tubing near the connection site to instill water.
      C)
      Place the tip of the syringe in the tube to gently instill warm water.
      D)
      Place the syringe in the blue air vent of a Salem sump or double-lumen tube.
      E)
      After instilling the water, hold the end of the NG tube over an irrigation tray.
      F)
      Observe for return of NG drainage into an available container.

    2. Which of the following signs and symptoms may lead the nurse to suspect hypovolemia?

      Select all that apply.

      A)
      Decreased skin turgor
      B)
      Increased urine output
      C)
      Dry mucous membranes
      D)
      Weight gain
      E)
      Low blood pressure

    3. The nurse is caring for a client with human immunodeficiency virus (HIV).

      ➢ Which of the following conditions, if present in the client, should make the nurse concerned about the client developing acquired immunodeficiency syndrome (AIDS)? Select all that apply.

      A)
      Chronic, progressive visual loss
      B)
      Kaposi’s sarcoma
      C)
      Wilms sarcoma
      D)
      Pulmonary tuberculosis
      E)
      Peripheral neuropathy
      F)
      Toxoplasma gondii

    4. The nurse is screening clients at risk of sudden infant death syndrome (SIDS).

      ➢ The nurse correctly identifies which client is at the greatest risk for SIDS? An infant who is

      A)
      a preterm 4-month-old female who sleeps supine and is formula fed.
      B)
      a preterm 12-month-old male who sleeps prone and is formula fed.
      C)
      a term 6-month-old male who sleeps supine and is formula fed.
      D)
      a preterm 3-month-old male who sleeps lateral and is breastfed.
    Page 4 of 38

    Exam Review

    1. The nurse reviews a client's antepartum nonstress test results as reactive.

      ➢ The nurse interprets this finding as

      A)
      fetal heart rate accelerations less than 15 beats per minute or lasting less than 15 seconds.
      B)
      no late decelerations of the fetal heart rate.
      C)
      late decelerations are present with a minimum of 50% of the contractions.
      D)
      two or more fetal heart rate accelerations within a 20-minute period.

    2. The nurse is triaging phone calls at a clinic for a group of clients.

      ➢ Which client situation requires immediate notification to the primary healthcare provider (PHCP)? A client who

      A)
      reports a strong metallic-like taste while taking newly prescribed metronidazole.
      B)
      reports a localized rash after starting prescribed sulfamethoxazole-trimethoprim.
      C)
      takes prescribed lithium and reports blurred vision.
      D)
      feels restless and reports difficulty sleeping while taking prescribed prednisone.

    3. The emergency department (ED) nurse cares for a child with epistaxis.

      ➢ Place the following actions in the order in which they need to be performed, starting from first to last.

      A)
      Have the child sit up with the neck forward or erect.
      B)
      Apply continuous pressure to the tip of the nose with thumb and forefinger for at least 10 minutes.
      C)
      Apply ice or a cold cloth to the bridge of the nose if the bleeding persists.
      D)
      Provide the child with a drink to wash away the taste of blood.
      E)
      Evaluate the bleeding to determine the effectiveness of the interventions.

    4. The nurse is reviewing a client's risk factors for placenta previa. Which of the following would be a risk factor for placenta previa?

      A)
      maternal cocaine use
      B)
      polycystic ovary syndrome
      C)
      nulliparity
      D)
      gestational diabetes
    Page 5 of 38

    Exam Review

    1. The nurse is caring for a newborn with neonatal abstinence syndrome (NAS). Which of the following actions would be appropriate for the nurse to take? Select all that apply.

      A)
      Keep the room fairly dark.
      B)
      Swaddle the infant in the flexed position.
      C)
      Provide the infant with a pacifier during crying spells.
      D)
      Plan to feed the infant less frequently
      E)
      Increase the lighting in the room to keep the infant awake.

    2. The nurse has taught a client scheduled for a liver biopsy. Which of the following statements by the client would indicate a correct understanding of the teaching?

      A)
      "I will not be conscious during this procedure."
      B)
      "I should not take any acetaminophen one week before this procedure."
      C)
      "I will need to cough and deep breathe every two hours after this procedure."
      D)
      "I may be asked to hold my breath during the insertion of the biopsy needle."

    3. The nurse assesses clients for the risk of developing hyperosmolar hyperglycemic syndrome.

      ➢ Which of the following clients should the nurse consider to be at greatest risk?

      A)
      63-year-old with diabetes mellitus (type two) who works outdoors and recently had an increased dosage of metformin.
      B)
      55-year-old with diabetes mellitus (type one) who was recently hospitalized for pneumonia and occasionally forgets to take their long-acting insulin.
      C)
      15-year-old with diabetes mellitus (type one) who has a hemoglobin A1C of 7.6% [ <7%] and has gained 4 lbs (1.8 kg) in the past month.
      D)
      45-year-old who was recently diagnosed with diabetes mellitus (type two) and was prescribed glipizide in addition to metformin.

    4. The nurse is caring for a client with a spinal cord injury experiencing shock.

      ➢ Which task can be delegated to unlicensed assistive personnel?

      A)
      Transport the client to the radiology department
      B)
      Perform passive range of motion
      C)
      Gather cardiac monitoring equipment
      D)
      Obtain vital signs
    Page 6 of 38