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    Exam Review

    1. An older adult client in a long-term care facility had a stroke 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility?
      A)
      Difficulty hearing some types of sounds
      B)
      A reddened area over the sacrum
      C)
      Stiffness in the lower extremities
      D)
      Difficulty moving the upper extremities
    2. A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to contribute to the client's plan of care?
      A)
      Auscultate breath sounds at least every 2 hr.
      B)
      Make sure the client has an intake of 2,000 to 3.000 mL of fluid per day.
      C)
      Apply anti embolic stockings.
      D)
      Perform range-of-motion exercises at least two to three times daily.
    3. A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?
      A)
      To confirm the placement of the NG tube
      B)
      To remove gastric acid that might cause dyspepsia
      C)
      To identify delayed gastric emptying
      D)
      To determine the client's electrolyte balance
    4. Which of the following is a modifiable risk factor associated with altered metabolism?
      A)
      Genetic predisposition
      B)
      Gender
      C)
      A sedentary lifestyle
      D)
      Age
    Page 1 of 10

    Exam Review

    1. A nurse is reinforcing teaching with a client who has osteoarthritis. To slow the degenerative process, which of the following interventions should the nurse recommend?
      A)
      Participating in exercises such as jogging and running
      B)
      Maintaining a BMI between 18.5 and 24.9
      C)
      Propping up the head with multiple pillows at night to promote restful sleep
      D)
      Taking 5000 mg acetaminophen in divided doses each day
    2. A nurse is collecting data on a client who has manifestations of osteoporosis. The nurse anticipates the provider will prescribe which of the following diagnostic tests?
      A)
      CT scan of the hip
      B)
      Long bone x-ray
      C)
      Bone density scan
      D)
      Serum calcium
    3. A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?
      A)
      Promote active range-of-motion activities.
      B)
      Add fluid and fiber to the diet.
      C)
      Request that the provider prescribe a stool softener.
      D)
      Avoid gas-producing foods.
    4. A nurse is collecting data from a client who is 12 hr postoperative following a colectomy with colostomy placement. Which of the following findings should the nurse report to the provider?
      A)
      No stool noted in the collection bag
      B)
      Slight bleeding of the stoma site
      C)
      Purplish colored stoma
      D)
      Edematous stoma
    Page 2 of 10

    Exam Review

    1. A nurse is preparing to administer an oral medication to an older adult client. The client states, "The pill I always take is green. I don't take an orange pill." Which of the following responses should the nurse give?
      A)
      "I will check your medication prescription again."
      B)
      "Let me explain the purpose of the medication."
      C)
      "Sometimes the same pill comes in a different color."
      D)
      "This is the medication that your doctor wants you to take."
    2. How do the kidneys regulate blood pressure through their secondary function?
      A)
      By directly pumping blood to increase blood pressure
      B)
      By filtering out excess glucose which can affect blood pressure
      C)
      By producing red blood cells to increase blood volume
      D)
      By secreting renin which activates the renin-angiotensin-aldosterone system (RAAS)
    3. A nurse is preparing to remove an NG tube for a client. Which of the following actions should the nurse take first?
      A)
      Verify provider order to discontinue the tube.
      B)
      Observe the amount and color of drainage.
      C)
      Perform hand hygiene and don gloves.
      D)
      Disconnect the tube from the wall suction.
    4. A nurse is preparing to administer potassium chloride to a client who has a potassium level of 5.8 mEq/L. Which of the following actions should the nurse take?
      A)
      Inform the provider of the client's potassium level.
      B)
      Obtain a prescription to increase the dosage of the medication.
      C)
      Give the medication as prescribed.
      D)
      Hold the medication until the client has his evening meal.
    Page 3 of 10

    Exam Review

    1. A nurse is caring for a young adult client who has ulcerative colitis and is scheduled for surgery to create an ileostomy. After speaking with the provider, the client says. "How will I ever be able to have a normal life after this?" Which of the following responses should the nurse make?
      A)
      "Are you worried that it will affect your relationship with your partner?"
      B)
      "Tell me how you think having the ileostomy will affect you."
      C)
      "This will cure your disease so you don't spend so much time in the hospital."
      D)
      "Everybody worries about how they will manage their ileostomy at first."
    2. A nurse is collecting data from a 21-year-old female client who has manifestations of obesity. Which of the following findings should indicate to the nurse the client is obese?
      A)
      BMI 31
      B)
      BMI 24
      C)
      BMI 28
      D)
      BMI 17
    3. A nurse is reviewing a client's laboratory results and sees that their hemoglobin A1C is 9%. Which of the following statements from the nurse is appropriate?
      A)
      "You have many dangerously low blood sugar levels."
      B)
      "Your average blood sugar is high."
      C)
      "Your blood sugar is very unstable."
      D)
      "Your blood sugar is too high after meals.”
    4. A nurse is talking about joint protection strategies with an older adult client who has osteoarthritis. Which of the following recommendations should the nurse reinforce?
      A)
      jog or run three times a week
      B)
      Maintain the recommended body weight.
      C)
      Choose soft pillowed chairs for sitting
      D)
      Reduce the amount of purine in the diet.
    Page 4 of 10

    Exam Review

    1. A nurse is contributing to the plan of care for a client who has frequent diarrheal stools. Which of the following interventions should the nurse include in the plan?
      A)
      Administer a soap-suds enema to cleanse the colon.
      B)
      Allow the perineal area to air dry after each stool.
      C)
      Provide the client with a high fiber diet.
      D)
      Apply an alcohol-free barrier to the perineal area after each stool.
    2. The nurse is caring for a client who has a bowel obstruction and a new prescription for the insertion of a nasogastric tube. Which of the following interventions should the nurse take when inserting the nasogastric tube?
      A)
      Withdraw the tube if the client gags during insertion.
      B)
      Place the client in a supine position.
      C)
      Measure the tube for insertion from the tip of the nose to the umbilicus.
      D)
      Instruct the client to place his chin to his chest and swallow.
    3. A nurse is planning to perform passive range of motion for a client who is immobilized. Which of the following actions should the nurse plan to take?
      A)
      Move body parts rapidly through the movements.
      B)
      Support extremities above and below joints.
      C)
      Continue moving body parts if muscle spasticity occurs.
      D)
      Stretch the body part just beyond the existing range of motion.
    4. A nurse is collecting data on a client who has had diarrhea for several days. Which of the following findings should the nurse expect?
      A)
      Decreased bowel sounds
      B)
      Rigid abdomen
      C)
      Hypothermia
      D)
      Dehydration
    Page 5 of 10

    Exam Review

    1. A nurse is reinforcing teaching with a young adult client who has a family history of osteoporosis. Which of the following health promotion activities should the nurse recommend?
      A)
      Engaging in weight-bearing exercise regularly
      B)
      Drinking a cup of coffee every morning
      C)
      Having a bone density scan every year
      D)
      Taking a 500 mg calcium supplement every day
    2. A nurse is providing care to a client who has osteoarthritis and is experiencing difficulty with mobility and cannot leave their house. Which of the following psychosocial health impacts is expected and requires further evaluation?
      A)
      Cardiovascular disease
      B)
      insomnia
      C)
      Cognitive impairment
      D)
      Depression
    3. A nurse is inserting an NG tube. Identify the sequence the nurse should follow. (Move the steps of NG tube insertion on the left into the box on the right, placing them in the selected order of performance. All steps must be used.)
      A)
      Place client in high Fowler's position.
      B)
      Advance tube downward and backward.
      C)
      Check position of tube and secure
      D)
      Measure tube for placement.
      E)
      Insert tube along the base of nares.
      F)
      Lubricate the tube
    4. A nurse is reinforcing teaching with a client has reports constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.
      A)
      increased fiber in the diet
      B)
      Inadequate fluid intake
      C)
      ignoring the urge to defecate
      D)
      Excessive laxative use
      E)
      increased activity
    Page 6 of 10