Exam Review

A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?
A)
“Eating a high fiber diet will reduce my risk for developing skin cancer.”.
B)
“I should check my skin monthly for any changes.”.
C)
“I should avoid the use of tanning booths.”.
D)
“I should use sunscreen even on cloudy days.”.
E)
“I should use sunscreen even on cloudy days.”.
A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?
A)
Avoid handwashing after eating.
B)
Avoid foods prepared with tap water.
C)
Avoid eating meat.
D)
Avoid covering sores with bandages.
A nurse is assessing a client. Which of the following actions should the nurse take to assess the posterior tibial pulse? (Select all that apply.)
(SATA)
A)
Palpate the area behind the ankle bone.
B)
Use the pads of the fingers to feel for the pulse.
C)
Compare the pulse strength with the other leg.
D)
Assess for any swelling or tenderness
The nurse reviews a primary health care provider’s prescriptions and notes that a topical nitrate is prescribed. The nurse notes that acetaminophen is prescribed to be administered before the nitrate. The nurse implements the prescription with which understanding about why acetaminophen is prescribed?
A)
Fever usually accompanies myocardial infarction.
B)
Acetaminophen does not interfere with platelet action as acetylsalicylic acid (aspirin) does.
C)
Headache is a common side effect of nitrates.
D)
Acetaminophen potentiates the therapeutic effect of nitrates.
E)
Acetaminophen potentiates the therapeutic effect of nitrates.

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Exam Review

A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. Which of the following findings should the nurse plan to monitor for and report to the provider immediately?
A)
Irregular pulse.
B)
Persistent fatigue.
C)
Dependent edema.
D)
Slurred speech.
A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client?
A)
Moist skin.
B)
Blood in the urine.
C)
Spider angiomas.
D)
Tarry stools.
A nurse is providing teaching to a group of clients. Which of the following clients is at risk for developing peripheral arterial disease?
A)
A client whose daily caloric intake is 25% fat.
B)
A client who has diabetes mellitus.
C)
A client who consumes two 12-ounce (0.35-L) alcoholic beverages daily.
D)
A client who has hypothyroidism.
The nurse, caring for a client with Buck’s traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction?
A)
Weak pedal pulses.
B)
Complaints of leg discomfort.
C)
Toes are warm and demonstrate a brisk capillary refill.
D)
Drainage at the pin sites.

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Exam Review

When considering the risk for heart failure, what would the nurse monitor the client diagnosed with infective endocarditis for on an ongoing basis?
A)
Flank pain with radiation to the groin, accompanied by hematuria.
B)
Respiratory distress, chest pain, and use of accessory muscles.
C)
Crackles, peripheral edema, and weight gain.
D)
Confusion, decreasing level of consciousness, and aphasia.
A nurse is caring for an older adult client who had a femoral head fracture 24 hr ago and is in skin traction. The client reports shortness of breath and dyspnea. The nurse should suspect that the client has developed which of the following complications?
A)
Airway obstruction.
B)
Pneumonia.
C)
Pneumothorax.
D)
Fat embolism.
A nurse is assessing a client who is in skeletal traction. The nurse should correct which of the following findings?
A)
The ropes are in the center of the wheel grooves.
B)
The ropes are securely attached to the pins.
C)
The weights are equal on each side.
D)
The weights rest against the foot of the bed.
A nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube. Which of the following actions should the nurse take before requesting a prescription for restraints? (Select all that apply.)
A)
Provide diversionary activities for the client.
B)
Assist the client with toileting at frequent intervals.
C)
Involve the family in the client’s care.
D)
Explain to the client that he will be restrained if he does not stop pulling on his NG tube.
E)
Use an electronic bed alarm device.

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Exam Review

Upon assessment, Cullen’s sign is noted. What complication of acute pancreatitis would the nurse suspect that the client might have?
A)
Pancreatic pseudocyst.
B)
Electrolyte imbalance.
C)
Internal bleeding.
D)
Pleural effusion.
A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skin traction. The nurse may remove the weights from the traction device if which of the following occurs?
A)
The client develops a life-threatening situation.
B)
The client has to be repositioned in the bed.
C)
The client complains of pain.
D)
The client needs to have an x-ray of the femur performed.
A nurse in a clinic is caring for a female client who has a new diagnosis of acne vulgaris on her cheeks. Which of the following should the nurse include in the teaching plan for this client?
A)
Use friction when washing the affected area.
B)
Use a new cosmetic pad with each limited application of makeup.
C)
Use an oil-based soap to wash affected areas daily.
D)
Express the larger comedones periodically.
A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse plan to implement?
A)
Vitamin B12 injections
B)
Blood transfusions
C)
Iron supplements
D)
Vitamin B6 supplements

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Exam Review

A nurse is talking with a client who has cholelithiasis and is about to undergo an oral cholangiogram. Which of the following client statements indicates to the nurse understanding of the procedure?
A)
“Soon those shock waves will get rid of my gallstones.”.
B)
“I’ll have a camera put down my throat so they can see my gallbladder.”.
C)
“They are going to use dye to examine my gallbladder and ducts.”.
D)
“They’ll put medication into my gallbladder to dissolve the stones.”.
A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site?
A)
The area surrounding the insertion site feels warm to the touch.
B)
The infusion rate has stopped but the tubing is not kinked.
C)
There is fluid leaking around the insertion site.
D)
There is no blood return when the tubing is aspirated.
A nurse is admitting a client who has sustained severe burn injuries in a grease fire. Using the Rule of Nines, the nurse should estimate that the client has burned the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.
A nurse is planning care for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care?
A)
Remove the vest daily to inspect the client’s skin integrity.
B)
Check that the halo jacket is snug against the client’s skin.
C)
Provide range of motion to the client’s neck.
D)
Monitor the client for an elevated temperature.

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Exam Review

A nurse is assessing a client who is 48 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
A)
Respiratory rate 18/min.
B)
Blood pressure 102/66 mm Hg.
C)
Yellow-green drainage on the surgical incision.
D)
Straw-colored urine from an indwelling urinary catheter.
A client with a diagnosis of valvular heart disease is being considered for mechanical valve replacement. Which circumstance is essential to assess before the surgery is performed?
A)
The ability to comply with anticoagulant therapy for life.
B)
The likelihood of the client experiencing body image problems.
C)
The physical demands of the client’s lifestyle.
D)
The ability to participate in a cardiac rehabilitation program.
A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hours following a burn injury?
A)
Dextrose 5% in water.
B)
0.45% sodium chloride.
C)
Dextrose 5% in 0.9% sodium chloride.
D)
Lactated Ringers.
A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching? (Select all that apply.)
A)
Wound infection.
B)
Obesity.
C)
Altered mental status.
D)
Pain medication administration.
E)
Poor nutritional state.

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