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    Exam Review

    1. A patient is receiving oxygen therapy via nasal cannula. The nurse finds the patient's oxygen saturation at 88%. Which intervention should the nurse implement first?
      A)
      Increase the oxygen flow rate.
      B)
      Document the current oxygen saturation.
      C)
      Call the respiratory therapist for an assessment.
      D)
      Reassess the oxygen saturation in 30 minutes.
    2. When measuring the respiratory rate of a patient, the nurse observes that the patient is using accessory muscles to breathe. What is the best interpretation of this finding?
      A)
      The patient is experiencing respiratory distress.
      B)
      The patient is relaxed and comfortable.
      C)
      The patient's oxygen saturation is likely to be above 95%.
      D)
      The patient needs immediate cardiopulmonary resuscitation.
    3. A nurse notices a postoperative patient with a temperature of 39°C (102.2°F). Which analysis of the situation is most accurate?
      A)
      The patient's fever is likely due to dehydration.
      B)
      The fever is a normal response to surgery.
      C)
      The increased temperature is due to stress response.
      D)
      The patient may have developed an infection.
    4. When measuring a patient's blood pressure, the nurse hears a sound that becomes muffled and then disappears. What does this indicate?
      A)
      The diastolic pressure.
      B)
      The need to inflate the cuff further.
      C)
      The patient is experiencing a heart murmur.
      D)
      The systolic pressure.
    Page 1 of 12

    Exam Review

    1. A client with limited mobility needs to be moved from a bed to a stretcher. Which assistive device should the nurse use?
      A)
      Transfer board
      B)
      Crutches
      C)
      Draw sheet
      D)
      Gait belt
    2. Which devices are appropriate for transferring a client with limited mobility from a bed to a chair? (Select all that apply)
      (SATA)
      A)
      Transfer board
      B)
      Wheelchair
      C)
      Draw sheet
      D)
      Gait belt
      E)
      Mechanical lift
      F)
      Stretcher
    3. During a routine check, a nurse finds a patient's blood pressure to be 150/95 mm Hg. What is the most appropriate next step?
      A)
      Immediately administer antihypertensive medication.
      B)
      Document the finding and recheck the blood pressure in 5 minutes.
      C)
      Inform the patient that their blood pressure is normal.
      D)
      Ask the patient to lie down and rest for 30 minutes before rechecking.
    4. A nurse is monitoring a patient who has been administered a beta-blocker. The patient's pulse rate has dropped to 50/min. What should the nurse analyze as a potential cause?
      A)
      The patient is experiencing a normal side effect of the medication.
      B)
      The patient's heart rate is likely unrelated to the medication.
      C)
      The patient's low pulse is due to dehydration.
      D)
      The beta-blocker is causing bradycardia.
    Page 2 of 12

    Exam Review

    1. A nurse is transferring a patient who uses a walker. Which of the following is a key consideration for ensuring the patient's safety during ambulation?
      A)
      The walker should be at the level of the patient's shoulders.
      B)
      The patient should walk inside the walker frame.
      C)
      The patient should lean forward while walking.
      D)
      The patient should use the walker to climb stairs.
    2. When preparing to transfer a client from a bed to a wheelchair, which actions should a nurse take to ensure safety and prevent injuries? (Select all that apply) (Select All that Apply.)
      (SATA)
      A)
      Lift the client without assistance to avoid delays
      B)
      Position the wheelchair at a 90-degree angle to the bed
      C)
      Use a gait belt to assist with the transfer
      D)
      Ensure the client is wearing non-slip footwear
      E)
      Stand with feet close together for better stability
      F)
      Lock the brakes on the bed and wheelchair
    3. A nurse measures a patient's oxygen saturation at 92%. What should be the nurse's next step?
      A)
      Check the patient's temperature
      B)
      Reassess oxygen saturation in one hour
      C)
      Document the finding and continue monitoring
      D)
      Administer supplemental oxygen
    4. In which situation is the use of a transfer board most appropriate?
      A)
      Helping a client ambulate down a hallway.
      B)
      Repositioning a client in bed.
      C)
      Transferring a client from a wheelchair to a car.
      D)
      Moving a client from a stretcher to a bed.
    Page 3 of 12

    Exam Review

    1. A nurse is assessing the vital signs of a patient who has just returned from surgery. The patient is experiencing tachycardia and hypotension. What should the nurse prioritize in this situation?
      A)
      Decrease the head of the bed.
      B)
      Increase the intravenous fluid rate.
      C)
      Administer pain medication.
      D)
      Check the surgical site for bleeding.
    2. Which of the following is a critical assessment before assisting a patient with ambulation?
      A)
      The patient's muscle strength and balance.
      B)
      The patient's meal preferences.
      C)
      The color of the patient's clothing.
      D)
      The patient's verbal communication skills.
    3. A nurse is assisting a client with limited mobility to transfer from a bed to a wheelchair. What is a critical safety step in this process?
      A)
      Locking the wheelchair and bed brakes.
      B)
      Having a third person assist without informing the client.
      C)
      Ensuring the client's eyes are closed during transfer.
      D)
      Using a transfer board for every transfer.
    4. A patient presents with hypotension and tachycardia. The nurse considers hypovolemia as a potential cause. What analysis supports this hypothesis?
      A)
      The patient is likely experiencing stress-induced hypertension.
      B)
      The patient has an infection causing these symptoms.
      C)
      The patient may have experienced fluid loss leading to decreased blood volume.
      D)
      The patient is experiencing a normal postural change reaction.
    Page 4 of 12

    Exam Review

    1. Which of the following strategies are effective in maintaining nurses' safety during client transfers? (Select all that apply)
      A)
      Maintaining a narrow base of support
      B)
      Using assistive devices for all transfers
      C)
      Keeping the center of gravity high
      D)
      Bending at the waist instead of the knees
      E)
      Facing the direction of movement
      F)
      Using proper body mechanics
    2. A nurse is analyzing a patient's vital signs and notices a respiratory rate of 28 breaths per minute. Which condition might this suggest?
      A)
      The patient is experiencing normal breathing patterns.
      B)
      The patient may be experiencing respiratory distress.
      C)
      The patient is likely well-hydrated.
      D)
      The patient is likely experiencing hypothermia.
    3. During a transfer, a client exhibits signs of dizziness. What should the nurse do first?
      A)
      Ignore the dizziness and reassure the client.
      B)
      Continue with the transfer quickly.
      C)
      Call for additional staff to assist.
      D)
      Stop the transfer and sit the client down safely.
    4. Which assistive device is most appropriate for repositioning a client in bed?
      A)
      Draw sheet
      B)
      Crutches
      C)
      Transfer board
      D)
      Gait belt
    Page 5 of 12

    Exam Review

    1. When transferring a patient with limited mobility, which assistive device is best suited for moving from bed to chair?
      A)
      Transfer belt
      B)
      Transfer board
      C)
      Continuous Passive Motion Machine
      D)
      Draw sheet
    2. Which principle of body mechanics should a nurse prioritize to avoid injury while transferring a patient?
      A)
      Maintaining a wide base of support.
      B)
      Twisting the torso while lifting.
      C)
      Bending at the waist.
      D)
      Keeping feet close together.
    3. A nurse is teaching a client how to use a walker. What instruction is most important to include?
      A)
      Use the walker only on carpets.
      B)
      Ensure the walker is too far ahead to maintain balance.
      C)
      Move the walker forward before stepping.
      D)
      Look down at the walker while moving.
    4. A patient with a history of hypertension presents with a blood pressure of 140/90 mm Hg. What action should the nurse take?
      A)
      Encourage the patient to rest and reassess in an hour.
      B)
      Administer antihypertensive medication as prescribed.
      C)
      Provide the patient with a low-sodium diet.
      D)
      Monitor vital signs every 4 hours.
    Page 6 of 12