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    Exam Review

    1. A nurse is replacing the dressing for a client who is postoperative following thoracic surgery. When assessing the surgical wound, which of the following findings should the nurse identify as an indication of infection?
      A)
      Pink coloration of the incision line
      B)
      Temperature 37.2° C (99° F)
      C)
      Swelling extending 3.8 cm (1.5 in) from the incision
      D)
      Crusting along the incision line
    2. A nurse is planning to perform gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following actions should the nurse take?
      A)
      Chill the lavage fluid before instilling it.
      B)
      Withdraw the fluid manually until it is clear.
      C)
      Position the client on his right side.
      D)
      Insert a small-bore NG tube.
    3. A nurse is assessing a client who is taking losartan. Which of the following findings should the nurse identify as an adverse effect of this medication?
      A)
      Hypertension
      B)
      Hyperactivity
      C)
      Dizziness
      D)
      Double vision
    4. A nurse is teaching a client about using transdermal scopolamine to treat motion sickness. Which of the following instructions should the nurse include?
      A)
      "Place the patch on your upper arm."
      B)
      "Replace a dislodged patch onto the same location."
      C)
      "Apply the patch prior to traveling."
      D)
      "Store unused patches in the refrigerator."
    Page 1 of 16

    Exam Review

    1. A nurse in an emergency department (ED) is assessing a preschooler who has a fractured arm. For which of the following should the nurse further investigate as a warning sign of child maltreatment?
      A)
      The guardian wants to accompany the child from the ED to the radiology department.
      B)
      The guardian states the child fell off the swing in the backyard.
      C)
      The child cries loudly when their arm is moved or manipulated.
      D)
      The child was brought to the ED 2 days after the injury occurred.
    2. A nurse is assessing a client who is receiving enteral feedings via an NG tube. The client has developed hyperosmolar dehydration. Which of the following actions should the nurse take when administering the client's feedings?
      A)
      Reposition the NG tube.
      B)
      Increase the rate of formula delivery.
      C)
      Switch to a lactose-free formula.
      D)
      Add water to the formula.
    3. A nurse is caring for a client who is preoperative for cataract removal. Which of the following statements by the client indicates an understanding of the procedure?
      A)
      "I know the provider will replace the lens in my eyes during this procedure."
      B)
      "I will see dark spots in my vision after this procedure."
      C)
      "I can expect my eyelids to be bruised after this procedure."
      D)
      "I will receive general anesthesia for this procedure."
    4. A nurse is preparing to administer medication to a client. Which of the following identifiers should the nurse use to identify the client?
      A)
      Room number
      B)
      Driver license number
      C)
      Place of birth
      D)
      Telephone number
    Page 2 of 16

    Exam Review

    1. A nurse is receiving information about four children during change-of-shift report. Which of the following children should the nurse assess first?
      A)
      A 5-year-old child who has type 1 diabetes mellitus and a blood sugar of 150 mg/dL (less than 200 mg/dL)
      B)
      A 12-year-old child who has cystic fibrosis and reports difficulty clearing secretions
      C)
      A 2-year-old child who has diarrhea and reports abdominal pain
      D)
      A 3-year-old child who has an atrial septal defect and a heart rate of 120/min
    2. A nurse is planning care for a client who is at 32 weeks of gestation and has severe preeclampsia. Which of the following actions should the nurse plan to take?
      A)
      Ensure that the side rails are up on the client's bed.
      B)
      Check the fetal heart rate twice daily.
      C)
      Provide the client with a low-protein diet.
      D)
      Ambulate the client every 4 hr.
    3. A nurse is caring for a preschooler who is in an acute care facility. Which of the following actions should the nurse take?
      A)
      Encourage the child to play with toys such as a pounding board.
      B)
      Perform the morning assessments when the parent is not in the room.
      C)
      Establish a new routine for the child to follow while in the facility.
      D)
      Use medical terminology when discussing procedures with the child.
    4. A nurse is part of a task force planning to audit a facility's nursing units concerning adherence to hand-hygiene protocols. Which of the following steps should the task force take first?
      A)
      Establish methods for collecting data within the facility.
      B)
      Take corrective measures to enforce hand hygiene.
      C)
      Compare the facility's data with the established criteria for hand hygiene.
      D)
      Determine the accepted standards for hand hygiene.
    Page 3 of 16

    Exam Review

    1. A nurse at an acute care facility is teaching a client about fall risk prevention strategies for use during their stay at the facility. Which of the following statements by the client indicates an understanding of the teaching?
      A)
      "I will wear a color-coded wristband, so everyone knows I am at risk of falling."
      B)
      "I should store my personal items all together on the shelf in my bathroom."
      C)
      "I should keep the overhead lights on at all times while I am here."
      D)
      "I will have to wear a restraint around my waist when I am sitting up in a chair."
    2. A nurse is planning postoperative care for a client who is scheduled for a thoracotomy with chest tube placement. Which of the following pieces of equipment should the nurse plan to have at the client's bedside?
      A)
      Padded clamp
      B)
      Tracheostomy tray
      C)
      Wire cutters
      D)
      Montgomery straps
    3. A nurse is planning assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)
      A)
      Transfer a client to physical therapy.
      B)
      Record a client's intake after each meal.
      C)
      Instruct a client on the use of an incentive spirometer.
      D)
      Obtain a client's vital signs every 4 hr.
      E)
      Insert an NG tube for a client who requires enteral feedings.
    4. A nurse is planning care for a client who is undergoing brachytherapy with a low-dose radiation implant for treatment of prostate cancer. Which of the following interventions should the nurse include in the client's plan of care?
      A)
      Instruct visitors to stay 1 m (3.3 feet) away from the client.
      B)
      Strain the client's urine.
      C)
      Limit each of the client's visitors to 2 hr per day.
      D)
      Attach a dosimeter to the client's gown.
    Page 4 of 16

    Exam Review

    1. A school nurse is using the Weber's test to check a child's hearing acuity. Which of the following actions should the nurse take?
      A)
      Measure the amount of time the child can hear the sound.
      B)
      Obtain a tympanogram reading prior to initiating the test.
      C)
      Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears.
      D)
      Place a vibrating tuning fork on the top of the child's head.
    2. A nurse is caring for a client who is postpartum and expresses concern about how her preschool-age son will react to having a baby sister. Which of the following strategies should the nurse suggest?
      A)
      "Hold your daughter when your son first meets her."
      B)
      "Give your son plenty of 'alone time' with his sister."
      C)
      "Plan for your son to meet his sister for the first time at home."
      D)
      "Give your son a little gift from his new sister."
    3. A nurse is planning care for a client who has a history of urinary tract infections (UTIs) and requires placement of an indwelling urinary catheter. Which of the following actions should the nurse take to help minimize the client's risk for acquiring a UTI?
      A)
      Loop the tubing so that it is lower than the collection bag.
      B)
      Keep the urinary bag at bladder level when ambulating.
      C)
      Secure the catheter to the client's thigh.
      D)
      Obtain urinary samples by disconnecting the tubing connections.
    4. A nurse is teaching a client who has a new prescription for metformin extended-release tablets. Which of the following statements by the client indicates an understanding of the teaching?
      A)
      "I will expect to gain weight."
      B)
      "I will avoid crushing this medication."
      C)
      "I will take the medication on an empty stomach."
      D)
      "I will take the medication in the morning."
    Page 5 of 16

    Exam Review

    1. A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids. Which of the following actions should the nurse take?
      A)
      Select a site proximal to previous venipuncture sites.
      B)
      Insert a larger gauge IV catheter to prevent phlebitis.
      C)
      Choose the client's dominant arm for IV access whenever possible.
      D)
      Initiate IV access on the palmar side of the client's wrist.
    2. A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take first?
      A)
      Attach a prefilled syringe to the catheter inflation hub.
      B)
      Position the sterile drape leaving the perineum exposed.
      C)
      Lubricate the catheter with water-soluble gel.
      D)
      Cleanse the client's meatus with antiseptic solution.
    3. A nurse is caring for a client who is 2 days postpartum. Which of the following findings should the nurse report to the provider?
      A)
      4+ deep-tendon reflexes
      B)
      Bilateral ankle edema
      C)
      Scant lochia rubra with a few small clots
      D)
      Urine output 2,500 mL/day
    4. A nurse is reviewing the medical record of a client who has a prescription for misoprostol for induction of labor. Which of the following findings is a contraindication for administration of this medication?
      A)
      Preeclampsia
      B)
      Postterm pregnancy
      C)
      Intrauterine growth restriction
      D)
      Transverse fetal lie
    Page 6 of 16