Exam Review

The nurse is preparing to provide wound care for a group of clients in the outpatient setting. The nurse understands which action is considered best practice when providing wound care?
A)
Complete every dressing change using sterile technique.
B)
Quickly remove any tape from the client's skin before beginning.
C)
Gather supplies before beginning wound care procedures.
D)
Document wound care at the end of the shift to save time.
The nurse plans care for a client with a wound. What action should the nurse incorporate into the client's care plan to minimize discomfort during wound care?
A)
Disregard client facial grimacing during the procedure and continue quickly.
B)
Administer pain medication at least 30 minutes before the dressing change.
C)
Cleanse the wound with cold solution to help numb the area.
D)
Remove the dressing quickly and without warning to reduce anxiety.
The nurse plans to perform a sterile procedure on a client at the bedside. Which action should the nurse plan to take first when setting up their sterile field?
A)
Open the sterile drape and place it on the table
B)
Put on sterile personal protective equipment
C)
Clean a work surface and raise it to waist level
D)
Arrange sterile instruments on the sterile field
A nurse provides care for several clients. Which client is at greatest risk of developing a pressure injury?
A)
An adolescent client with diabetes mellitus who is admitted for hyperglycemia.
B)
A middle-aged adult client who is comatose following a stroke.
C)
An older adult client who is recovering from a sinus infection.
D)
An adult client with a spinal cord injury who engages in daily physical therapy.

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Exam Review

The nurse is making an occupied bed. What action should the nurse implement?
A)
Face the direction of movement.
B)
Stand with feet close together.
C)
Reach across the bed to grab clean linens.
D)
Maintain the bed in low and locked position.
A nurse is planning client education about active range of motion (ROM) exercises. Which instruction should the nurse plan to include in the teaching?
A)
Perform exercises until you feel pain in the joint.
B)
Move each joint until there is resistance and then stop.
C)
Expose the entire body to observe overall movement.
D)
Perform exercises rapidly to increase muscle strength.
Which statement(s) are true when selecting and applying a dressing for a client with a wound? Select all that apply.
(SATA)
A)
A dressing helps protect the wound from contamination.
B)
The wound and the surrounding skin need to be cleaned with each dressing change.
C)
A dressing is required for an open wound with extensive tissue loss.
D)
The dressing type should stay the same throughout the course of wound treatment.
E)
The dressing should control drainage without fully drying out the wound bed.
The following six questions are part of an unfolding case study. Review the electronic health record. Which 3 assessment finding(s) require follow-up by the nurse? Select three findings.
(SATA)
A)
Blood pressure
B)
Respiration rate
C)
Lack of ambulation
D)
Body mass index
E)
Oxygen saturation

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Exam Review

Review the electronic health record. For each assessment finding, click to specify whether the finding is a likely complication or unlikely complication.

	Likely Complication	Unlikely Complication
Blood pressure of 120/82 mmHg		✓
Body mass index of 26.6		✓
Respiration rate of 26 breaths per minute	✓
Heart rate of 115 beats per minute	✓
Oxygen saturation of 88% on room air	✓

Review the electronic health record. Complete the sentence using the drop-down lists. Based on the client's history and assessment findings, the client is at highest risk for developing ▾ atelectasiscaused by▾ alveolar collapse.
Dropdown 1:
Option 1: bowel obstruction
Option 2: infection
Option 3: atelectasis
Option 4: alveolar collapse
Dropdown 2:
Option 1: bowel obstruction
Option 2: infection
Option 3: atelectasis
Option 4: alveolar collapse
Review the electronic health record. For each potential nursing intervention, click to specify whether the intervention is indicated or contraindicated
A)
Provide a high-fiber diet rich in fruits and vegetables
B)
Reposition the client every 1-2 hours
C)
Apply thromboembolic deterrent (TED) hose
D)
Decrease fluid intake to less than 1500 mL a day
E)
Complete all hygiene care for the client
F)
Encourage the client to cough and deep breathe
Review the electronic health record. Which action(s) should the nurse take when assisting the client to use a weight-bearing gait with a standard walker? Select all that apply.
A)
Adjust the walker height so the client's arms are fully extended when holding the handles.
B)
Stand slightly behind and on the affected side of the client when they are using a walker.
C)
Have the client lift the device up and forward. Do not allow them to skid it along the floor.
D)
Instruct the client to move the walker forward and then move their affected side forward.
E)
Ensure the client is wearing non-skid footwear before ambulating with the walker.

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Exam Review

Review the electronic health record. The nurse is preparing the client for discharge. After the nurse provides education about the use of a cane, which statement by the client indicates understanding?
A)
“I will use the cane to support all of my weight when walking."
B)
"I will make sure my elbow is bent slightly when I hold the cane."
C)
"I will move the strong leg up the stairs first, then the cane, and then the weak leg."
D)
“I will hold the cane on the weak side of my body to support it."
For each asepsis example, click to specify whether it describes medical asepsis or surgical asepsis.
A)
Disinfecting a client's counter before administering oral medications
B)
Covering the client and surrounding area with sterile drapes
C)
Coving mouth and nose with a sue or elbow when coughing or sneezing
D)
Allowing only sterile-to-sterile contact
E)
Using sterile packaging for instruments and supplies
F)
Using an autoclave to sterilize surgical instruments
The nurse is planning to assist a client to transfer from the bed to the chair. Which healthcare provider order should the nurse consider in planning for the client's transfer to the chair?
A)
Maintain intravenous (IV) access
B)
No weight bearing to the right lower leg
C)
Change wound dressing twice daily
D)
Perform skin assessment every 12 hours
The nurse plans care for a client with a wound positive for methicillin-resistant Staphylococcus aureus (MRSA). What action should the nurse include in the care of this client?
A)
All visitors should wear hair and shoe covers.
B)
All visitors should wear a gown and gloves.
C)
All visitors should wear goggles and gloves.
D)
All visitors should wear an N95 mask and gown.

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Exam Review

The nurse provided discharge teaching to the client's family on preventing pressure injuries at home. Which statement made by the family member indicates a need for further instruction?
A)
"I will encourage him to walk daily so his muscles get stronger."
B)
"I will ensure he inserts his dentures so he can eat well during the day."
C)
"I will remind him to shift in his chair at least every two hours."
D)
"I will change his incontinence brief about every eight hours or so."
Date/Time: 4/11/XXX 1402 Review the electronic health record. What is the client's risk for falls?
A)
Low risk
B)
Moderate risk
C)
High risk
D)
Very high risk
The nurse cares for a group of clients in the emergency department. Which client should the nurse see first?
A)
A client with dementia who refuses to have the pulse oximeter on their finger.
B)
A client with a blood pressure of 138/86 mmHg who is experiencing acute pain.
C)
A client with delirium who is confused and has a temperature of 101.8 F (38.8 C).
D)
A client with a heart rate of 112 who is experiencing elevated levels of anxiety.
A nurse cares for a client with a respiratory rate of 6 breaths per minute and an oxygen saturation of 71% What action should the nurse take first?
A)
Sit the client up in High Fowler's
B)
Call the rapid response team
C)
Monitor respiratory rate and depth
D)
Prepare for possible intubation

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Exam Review

Which term describes the difference between the systolic and diastolic readings?
A)
Blood pressure
B)
Pulse pressure
C)
Cardiac output
D)
Heart rate
The nurse is caring for a client who fell through the ice while ice skating. To prevent further decrease in body temperature, which action should the nurse take first?
A)
Place a hat on the client's head.
B)
Remove wet clothes, replacing them with dry ones.
C)
Provide hot liquids once the client is conscious.
D)
Place a warming blanket over the client.
A client on neutropenic precautions asks the nurse if visitors can bring gifts. How should the nurse respond?
A)
"Visitors can bring you a potted plant for your room."
B)
"Visitors can bring you fresh fruit from the market."
C)
"Visitors can bring you paper flower arrangements."
D)
"Visitors can bring you your favorite raw vegetables."
A nurse is caring for a client with measles. Which isolation precautions should the nurse implement?
A)
Contact
B)
Standard
C)
Droplet
D)
Airborne

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