Exam Review

A nurse is reinforcing discharge teaching with a client following an episode of status asthmaticus. The client has a prescription for two inhalations from an albuterol metered-dose inhaler. Which of the following statements by the client indicates an understanding of the teaching?
A)
I will wait 10 min between each inhalation.
B)
I will tilt my head forward while inhaling the medication.
C)
I will hold the inhaler with my non-dominant hand.
D)
I will hold my breath at least 10 seconds after inhaling the medication.
A nurse is assisting with the admission of a client who has tuberculosis with a productive cough. Which type of isolation precautions should the nurse initiate for the client?
A)
Droplet.
B)
Airborne.
C)
Protective.
D)
Contact.
A nurse is reinforcing teaching with a newly licensed nurse about reading a client's ECG tracing. The nurse should include in the teaching that the P wave represents which of the following cardiac electrical activities?
A)
Atrial depolarization.
B)
Ventricular depolarization.
C)
Late ventricular repolarization.
D)
Early ventricular repolarization.
A nurse in a provider's office is collecting data from a client who has hypothyroidism. Which of the findings should the nurse expect?
A)
Bradycardia.
B)
Moist skin.
C)
Insomnia.
D)
Blurred vision.

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Exam Review

A nurse is caring for an older adult client who has left-sided heart failure. Which of the following findings should the nurse expect?
A)
Nocturnal polyuria.
B)
Frothy sputum.
C)
Jugular distention.
D)
Dependent edema.
A nurse is assisting with the care of a client who is postoperative following surgical repair of a fractured mandible. The client's jaw is wired shut to repair and stabilize the fracture. The nurse should recognize which of the following is the priority action?
A)
Relieve the client's pain.
B)
Prevent aspiration.
C)
Check the client's pressure points for redness.
D)
Provide oral hygiene.
A nurse is caring for a hospitalized client who has bipolar disorder and is disturbing other clients with incessant talking. Which of the following actions should the nurse take?
A)
Inform the client that restraints may be necessary if she cannot control her behavior.
B)
Allow the client to interact freely with others on the unit.
C)
Escort the client to her room when she is observed trying to interact with other clients.
D)
Assist the client to practice social interaction with peers during a community meeting.
A nurse is caring for a client who reports acute anxiety. Which of the following actions should the nurse take first?
A)
Remain with the client.
B)
Have the client identify two coping skills.
C)
Encourage verbalization of feelings.
D)
Provide an activity for diversion.

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Exam Review

A nurse is providing teaching about dietary supplements to a client who has erectile dysfunction and has been prescribed nitroglycerin. Which of the following statements is the most important for the nurse to include in the teaching?
A)
There is not enough evidence that dietary supplements are effective for erectile dysfunction.
B)
Dietary supplements can cause a drug-drug interaction with nitrates.
C)
Dietary supplements may be expensive and are not typically covered by insurance.
D)
Dietary supplements have not been tested and approved by the government.
A nurse is assisting with caring for a client who has a new concussion following a motor-vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?
A)
Nuchal rigidity.
B)
Battle's sign.
C)
Lethargy.
D)
Polyuria.
A nurse is collecting data from a client who has leukemia. Which of the following findings has the highest priority?
A)
Platelet count 125,000/mm.
B)
Bone pain.
C)
Hematocrit 35
D)
Weight loss.
A nurse is assisting with the admission of a client who is at 39 weeks of gestation and has heavy vaginal bleeding. Which of the following actions should the nurse take?
A)
Administer antibiotics.
B)
Initiate an IV infusion of magnesium sulfate.
C)
Prepare for cesarean birth.
D)
Request the RN perform a cervical examination.

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Exam Review

A nurse is caring for a client who has just had a bronchoscopy. Which of the following actions should the nurse take?
A)
Have the client refrain from talking for 24 hr.
B)
Suction the client's oropharynx frequently.
C)
Withhold food and liquids until the client's gag reflex returns.
D)
Irrigate the client's throat every 4 hr.
A nurse is collecting data from a client who has atrial fibrillation. When documenting the quality of the client's pulse, which of the following terms should the nurse use?
A)
Bounding.
B)
Not palpable.
C)
Irregular.
D)
Slow.
A nurse is caring for a client on an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?
A)
Whether the client is unwilling to accept that treatment is needed.
B)
Whether the client is unable to make arrangements to stay with someone.
C)
Whether the client is financially incapable of paying for prescribed medications.
D)
Whether the client is a danger to herself or others.
A nurse is planning care for a group of clients. When planning the assignment for an assistive personnel (AP), which of the following activities should the nurse consider unsafe for the AP to perform?
A)
Administering a cleansing enema to a client who is preoperative.
B)
Assisting an older adult client to take acetaminophen the AP crushed in applesauce.
C)
Obtaining a urine specimen for a urinalysis from a client on admission.
D)
Measuring the vital signs of a client who has a history of angina.

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Exam Review

A nurse caring for a client who requires isolation has just finished a care procedure. Which of the following pieces of personal protective equipment (PPE) should the nurse remove last?
A)
Eyewear.
B)
Mask.
C)
Gown.
D)
Gloves.
A nurse is reinforcing teaching about pernicious anemia with a client following a total gastrectomy. Which of the following dietary supplements should the nurse include in the teaching as the treatment for pernicious anemia?
A)
Vitamin B12.
B)
Folate.
C)
Iron.
D)
Vitamin C.
A nurse is preparing to count the controlled substances in the secure cabinet. Which of the following actions should the nurse take?
A)
Verify that the amounts of each medication she counts match the amounts on the inventory record.
B)
Set aside any controlled substances the nurse plans to give during her shift.
C)
Discard any partial doses she finds in the cabinet in the sharps container.
D)
Co-sign any notations of wasting controlled substances on the previous shift.
A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?
A)
Dyspnea.
B)
Frothy sputum.
C)
Peripheral edema.
D)
Orthopnea.

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Exam Review

A nurse is reinforcing teaching about a high-fiber diet with a client who has constipation. Which of the following foods should the nurse include as sources of fiber? (Select all that apply.)
A)
Lean turkey.
B)
Kidney beans.
C)
Whole wheat bread.
D)
Strawberries.
E)
Peanut butter.
A nurse is reinforcing teaching with a client who has neutropenia. Which of the following instructions should the nurse include in the teaching?
A)
Participate in gardening for mild exercise.
B)
Eat plenty of fresh fruits and vegetables.
C)
Take temperature weekly.
D)
Avoid crowded places.
A nurse is collecting data from a 6-year-old child at a well-child visit. Which of the following statements by the child's parent should the nurse report to the provider?
A)
"My child often cheats when we play board games.”.
B)
"Sometimes my child has temper tantrums.”.
C)
"The teacher says my child has to squint to see the board.”.
D)
"My child has recently lost both front top teeth.”.
An assistive personnel (AP) says to the nurse, "This client is incontinent of stool three or four times a day. I get angry because I think that the client might be doing it just to get attention.”. Which of the following responses by the nurse is therapeutic?
A)
"You are probably right. Soiling the bed is a way of getting attention from the nursing staff.”.
B)
"Next time this happens, tell me and I'll talk to the client about his behavior.”.
C)
"Tell me what makes you feel the client is doing this on purpose?"
D)
"Why don't you spend more time with the client if you think that she is trying to get attention?"

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