Exam Review

The emergency department triage nurse receives notification there has been a mass shooting incident at a local shopping mall with several casualties injured. The hospital’s emergency response plan is initiated. Which client should the nurse prioritize for care?
A)
Client with a sucking chest wound, conscious, blood pressure 88/58 mm Hg, heart rate 115/min, and red tag observed.
B)
Client with a significant penetrating head wound, unconscious with irregular breathing pattern, and black tag observed.
C)
Client with superficial lacerations to the left arm and left lower leg.
D)
Client with closed left lower leg injury, air cast in place, pain reported as 9 on a 0 to 10 numeric pain scale.
The nurse should identify that Client 1 requires priority care due to which of the following reasons?
A)
The client has severe but survivable injuries.
B)
The client has minor injuries requiring immediate care.
C)
The client has non-life-threatening injuries but requires follow-up care.
D)
The client has injuries that do not require urgent attention.
Which client should receive immediate intervention based on the following details?
A)
Client with a sucking chest wound, conscious, blood pressure 88/58 mm Hg, heart rate 115/min, and red tag observed.
B)
Client with a significant penetrating head wound, unconscious with irregular breathing pattern, and black tag observed.
C)
Client with superficial lacerations to the left arm and left lower leg, occlusive dressing in place, tearful, blood pressure 118/78 mm Hg, and green tag observed.
D)
Client with closed left lower leg injury, air cast in place, pain reported as 9 on a 0 to 10 numeric pain scale, and yellow tag observed.
Which prescription should the nurse clarify with the provider prior to administration?
A)
Potassium Chloride 20 mEq PO daily.
B)
HCTZ 25 mg PO daily.
C)
Amlodipine 10 mg PO daily.
D)
Clonidine 1 mg PO TID PRN for systolic blood pressure of 180.

Page 1 of 15

Exam Review

A nurse is caring for a client in the emergency department. Which action should the nurse take based on the client’s medication administration record at 1130?
A)
Administer Albuterol nebulizer 2.5 mg stat.
B)
Administer Methylprednisolone 50 mg IV stat.
C)
Reassess the client’s vital signs before administering medications.
D)
Notify the provider if the client has worsening symptoms after administration.
Based on the physical exam findings, which assessment indicates the client’s condition is worsening?
A)
Cyanotic mucous membranes and oxygen saturation of 84% on 3 L nasal cannula.
B)
Diffuse wheezing auscultated throughout lung fields and hand tremor present.
C)
Blood pressure of 168/90 mm Hg and heart rate of 98/min.
D)
Clear rhinorrhea visible and skin warm and dry.
A nurse is caring for a client on a medical-surgical unit. Which intervention should the nurse prioritize?
A)
Monitoring blood pressure trends after administering antihypertensive medication.
B)
Administering prescribed Potassium Chloride 20 mEq PO STAT.
C)
Reassessing the client for additional medication needs at 1300.
D)
Educating the client about the importance of maintaining stable blood pressure levels.
Which of the following is correct about a nurse hygiene?
A)
Wash hands with cold water for at least 15 seconds and dry with a towel.
B)
Wash hands with soap and warm water for at least 10 seconds and air dry.
C)
Wash hands with soap and warm water for at least 15 seconds and then dry hands with a clean paper towel.
D)
Wash hands with only water and dry with a clean paper towel.

Page 2 of 15

Exam Review

A nurse is providing teaching about measures to promote sleep with a client who has insomnia. Which of the following client statements indicates an understanding of the teaching?
A)
“I can exercise as late as 1 hour before bedtime.”.
B)
“I should reduce my fluid intake 2 hours before bedtime.”.
C)
“I should take an hour nap each day.”.
D)
“I can eat a large meal as late as 1 hour before bedtime.”.
A nurse is documenting client care. Which of the following entries should the nurse identify as an example of implementation of client care?
A)
“Vomited 120 mL of clear yellow emesis.”.
B)
“Reports stomach pain as 3 on pain scale.”.
C)
“Denies further nausea or vomiting since antiemetic administration.”.
D)
“Contacted the provider to report client findings.”.
A nurse is caring for a client who expresses anxiety about an upcoming surgery. Which of the following actions should the nurse take?
A)
Ask the client to describe their feelings.
B)
Inform the client that others have had the procedure without problems.
C)
Discuss the competency of the surgeon with the client.
D)
Ask the client why they are experiencing anxiety.
A nurse is planning to administer several medications to a client through a nasogastric (NG) tube. Which of the following actions should the nurse take?
A)
Dissolve crushed tablet medications in sterile water.
B)
Mix the medications together and administer through the NG tube.
C)
Crush the sublingual medication into powder form.
D)
Flush the tube with 5 mL saline between each medication.

Page 3 of 15

Exam Review

A nurse is planning a community education program about colorectal cancer. Which of the following risk factors should the nurse identify as modifiable?
A)
Smoking.
B)
Alcohol consumption.
C)
High-fat diet.
D)
Colorectal polyps.
A nurse is reviewing the laboratory report of a client who has been experiencing a fever for the last 3 days. Which of the following laboratory results indicates the client is experiencing fluid volume deficit?
A)
Decreased blood urea nitrogen (BUN).
B)
Increased hematocrit.
C)
Decreased urine specific gravity.
D)
Increased calcium level.
A community health nurse is teaching a group of clients about first aid for different types of wounds. Which of the following client statements indicates an understanding of the teaching?
A)
“I should apply clean dressings over the top of blood-saturated dressings and hold pressure.”.
B)
“I can clean wounds with hydrogen peroxide.”.
C)
“I can carefully remove the object from a penetrating wound.”.
D)
“I should place the affected area in a dependent position.”.
A nurse enters a client’s room and sees smoke coming from the trash can. Which of the following actions should the nurse take first?
A)
Pull the fire alarm.
B)
Close the fire doors.
C)
Evacuate the room.
D)
Extinguish the fire.

Page 4 of 15

Exam Review

A nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. The nurse should instruct the client to avoid which of the following foods?
A)
Orange slices.
B)
Ground hamburger.
C)
Cooked green beans.
D)
Canned peaches.
A nurse is caring for a client who has been recently hospitalized. The nurse should identify that which of the following findings indicates that the client is experiencing stress?
A)
Dry skin.
B)
Increased urinary output.
C)
Dilated pupils.
D)
Hyperactive bowel sounds.
A nurse is admitting a client who has meningococcal meningitis. Which of the following actions should the nurse take first?
A)
Administer antibiotic therapy to the client.
B)
Provide the client with analgesics as needed.
C)
Initiate droplet precautions for the client.
D)
Educate the client about the meningococcal infection.
A nurse is caring for a client who expresses feeling overwhelmed that their partner has alcohol use disorder and has been unable to keep a job for longer than 3 months. Which of the following is an appropriate response by the nurse?
A)
“I’m sure your situation will get better with time.”.
B)
“It must be terrible to be in this situation.”.
C)
“If I were you, I would talk with the hospital chaplain.”.
D)
“Tell me what you’ve done in the past to cope with your problems.”.

Page 5 of 15

Exam Review

A nurse is assessing the IV infusion site of a client who reports pain. The site is swollen and there is warmth along the course of the vein. Which of the following actions should the nurse take?
A)
Initiate a new IV line below the original insertion site.
B)
Discontinue the infusion.
C)
Raise the head of the bed.
D)
Obtain a culture from the area of the insertion site.
A nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. Which of the following actions should the nurse take to prevent contamination during the dressing change?
A)
Begin the dressing change by applying sterile gloves and removing the existing dressing.
B)
Remove a piece of the new dressing that falls 5 cm (2 in) from the edge of the sterile field during the dressing change.
C)
Place the existing dressing on the outermost portion of the sterile field and discard it.
D)
Restart the procedure if the sterile solution splashes onto the sterile field when pouring the solution into the dressing tray.
A nurse is assessing the pain level of a client who has dementia and difficulty communicating. Which of the following pain assessment techniques should the nurse use?
A)
Numerical pain scale.
B)
Verbal description.
C)
FACES pain scale.
D)
Behavioral indicators.
A nurse is completing an admission assessment for a client who has hearing loss. Which of the following actions should the nurse take?
A)
Limit the use of hand gestures when communicating with the client.
B)
Speak to the client with an increased volume.
C)
Use written materials to assist with communication.
D)
Limit visitors to avoid misunderstandings in communication.

Page 6 of 15