Exam Review

A nurse is caring for a client who reports burning around the peripheral IV site. Which of the following findings should the nurse identify as a manifestation of infiltration?
A)
Dryness
B)
Edema
A nurse is caring for a client on a medical-surgical unit. Exhibits Complete the following sentence by using the list of options. The nurse should ▾ wash hands with soap and warm water for at least 15 seconds, and then ▾ dry hands with a clean paper towel.
Dropdown 1:
Option 1: wash hands with soap and warm water for at least 15 seconds
Option 2: dry hands with a clean paper towel
Option 3: Apply alcohol-based hand rub to visibly soiled hands
Option 4: Use gloves instead of hygiene if only a small amount of blood is present
Dropdown 2:
Option 1: wash hands with soap and warm water for at least 15 seconds
Option 2: dry hands with a clean paper towel
Option 3: Apply alcohol-based hand rub to visibly soiled hands
Option 4: Use gloves instead of hygiene if only a small amount of blood is present
A nurse is planning teaching about meditation for a client who reports feeling anxious. Which of the following statements should the nurse include in the teaching?
A)
"Picture yourself in one of your favorite places."
B)
"Choose a word to help focus your attention."
C)
"Quickly inhale deeply and hold your breath for 30 seconds."
D)
"Plan for 1 hour of meditation for each session."
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 pitch.
C)
Use written materials to assist with communication.
D)
Limit visitors to avoid communication misunderstandings.

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Exam Review

A nurse is caring for a client in the emergency department. Exhibits
(Highlight — findings requiring follow-up are marked)
A nurse is caring for a client in the emergency department.

Exhibits

Click to highlight the findings that indicate client's condition is worsening. To deselect a finding, click on the finding again.

Physical Exam:

1200:

Client re-evaluated following nebulizer treatment. Client appears anxious, hand tremor present. Mucous membranes cyanotic, clear rhinorrhea visible. Diffuse wheezing auscultated throughout lung fields. S1,S2 auscultated, no murmur. Skin warm and dry.

Vital Signs

1150:
- Temperature 37° C (98.6" F)
- Heart rate 98/min
- Respiratory rate 27/min
- Blood pressure 168/90 mm Hg
- Oxygen saturation 84% on 3L nasal cannula
A nurse is preparing to perform a routine abdominal assessment for a client. Which of the following actions should the nurse take?
A)
Document shiny, taut skin as an expected finding
B)
Perform palpation after auscultation.
C)
Listen for 1 min before documenting absent bowel sounds.
D)
Perform auscultation immediately after the client has consumed a meal.
A nurse is caring for a client in the emergency department. Exhibits Complete the following sentence by using the lists of options. To implement the provider's prescriptions the nurse should ▾ encourage the client to swallow small sips of water and advance tube as patient swallows because this will ▾ facilitate the passage of the tube
Dropdown 1:
Option 1: advance tube during inspiration or coughing
Option 2: encourage the client to swallow small sips of water and advance tube as patient swallows
Option 3: extend the client's head away from chest after tube has passed through nasopharynx
Option 4: apply sterile gloves
Dropdown 2:
Option 1: open the glottis
Option 2: reduce the risk of aspiration
Option 3: reduce the transmission of microorganisms
Option 4: facilitate the passage of the tube
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 a 1 hour nap each day."
D)
"I can eat a large meal as late as 1 hour before bedtime."

Page 2 of 13

Exam Review

A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the teaching?
A)
"I need to have an attorney sign my advance directives."
B)
"I have a living will that outlines my wishes if I am unable to make decisions."
C)
"I must have a family member appointed to make my health care decisions."
D)
"I will need to sign a document stating that I want to be resuscitated if I require CPR."
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 documenting client care. Which of the following entries should the nurse identify as an example of implementation of client care?
A)
"Contacted the provider to report client findings."
B)
"Reports stomach pain as 3 on a pain scale of 0 to 10,"
C)
"Vomited 120 mL of clear, yellow emesis."
D)
"Denies further nausea or vomiting since antiemetic administration."
A nurse is preparing to obtain the oxygen saturation of a client who has peripheral edema and thickened toenails. Which of the following actions should the nurse take?
A)
Attach a probe carefully to the client's finger to prevent discomfort.
B)
Apply a sensor pad to the client's forehead.
C)
Secure a probe to one of the client's toes.
D)
Obtain a pulse oximetry reading when peripheral edema has decreased.

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Exam Review

A nurse is assessing a client who is receiving oxygen therapy. Which of the following findings should the nurse identify as a late manifestation of hypoxia?
A)
Bradypnea
B)
Restlessness
C)
Hypertension
D)
Tachycardia
A nurse is assisting a client who signed an informed consent form for surgery but has since expressed doubts about the need for surgery. Which of the following statements should the nurse make?
A)
"The procedure can't be cancelled once the consent is signed."
B)
"It's in your best interest to have this surgery now."
C)
"The surgeon will answer your questions before surgery."
D)
"Let me explain the surgery to you."
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)
Remove a piece of the new dressing that falls 5 cm (2 in) from the edge of the sterile field during the dressing change.
B)
Begin the dressing change by applying sterile gloves and removing the existing dressing
C)
Restart the procedure if the sterile solution splashes onto the sterile field when pouring the solution into the dressing tray.
D)
Place the existing dressing on the outermost portion of the sterile field and discard it when the dressing change is finished.
A nurse finds a client on the floor of their room experiencing a seizure. Which of the following actions is the nurse's priority?
A)
Place the client on their side with their head forward.
B)
Administer an anticonvulsant medication.
C)
Time the length of the client's seizure.
D)
Loosen the client's gown and allow them to move freely

Page 4 of 13

Exam Review

A nurse is caring for a client who has a nonpalpable skin lesion that is less than 0.5 cm (0.2 in) in diameter. Which of the following terms should the nurse use to document this finding?
A)
Papule
B)
Vesicle
C)
Nodule
D)
Macule
A nurse is planning a community education program about colorectal cancer. Which of the following risk factors should the nurse identify as modifiable? (Select all that apply.)
A)
Smoking
B)
Alcohol consumption
C)
Inflammatory bowel disease
D)
High-fat diet
E)
Colorectal polyps
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 in a provider's office is assessing the motor skill development of a 15-month-old toddler during a well-child visit. Which of the following gross motor skills should the nurse expect?
A)
Takes several steps on tip toes
B)
Walks without assistance using a wide stance
C)
Has an accentuated cervical curvature when standing
D)
Stands with the feet turned slightly inward

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Exam Review

A nurse is teaching a group of assistive personnel about the expected integumentary changes in older adult clients. Which of the following findings should the nurse include in the teaching?
A)
Increase in subcutaneous tissue
B)
Decrease in pigmentation
C)
Increase in moisture levels
D)
Decrease in elasticity
A nurse is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. Which of the following findings should the nurse expect?
A)
Pulse oximetry reading of 95%
B)
Decreased depth of respirations
C)
Flaring of the nostrils
D)
Respiratory rate of 16/min
A nurse is caring for a client who has dementia and frequently tries to get out of bed. Which of the following actions should the nurse take? (Select all that apply.)
A)
Turn on the bed alarm.
B)
Maintain the bed in the lowest position.
C)
Place the client in a vest restraint.
D)
Administer a sedative.
E)
Encourage the family to stay with the client.
A nurse is preparing to transfer a client from a chair to the client's bed. The client can bear partial weight and has upper body strength. Which of the following devices should the nurse use to transfer the client?
A)
A stand-assist lift
B)
A footboard
C)
A slide board
D)
A mechanical lift with a full body sling

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