Exam Review
- During a bath, the nurse notices redness and a potential pressure ulcer on the client's sacral area. What should the nurse do next?A)Apply a topical ointment and continue with the bath.B)Cover the area with a bandage to prevent infection.C)Document the findings and report to the healthcare provider.D)Ignore it since it is a common issue in bedridden clients.
- A nurse needs to communicate an urgent situation involving a client who has deteriorating vital signs. Using the ISBARR tool, what should the nurse prioritize immediately after introducing themselves and stating their role?A)Request specific recommendations from the provider.B)Describe the current client condition and critical changes requiring attention.C)Read back the orders given by the provider for clarification.D)Provide detailed background information including medical history.
- As an LVN, you are working in an intraprofessional team on a medical-surgical unit. Which of the following tasks is most appropriate for you to perform in collaboration with the RN?A)Interpreting lab results and making clinical decisions based on them.B)Administering intravenous medications without supervision.C)Developing the initial care plan for a new patient.D)Collecting and documenting vital signs and reporting abnormal findings to the RN.
- What is the nurse's primary role when performing a health assessment for a client with limited health literacy?A)To focus solely on verbal communication,B)To adapt teaching methods based on the client's preferences and understandingC)To disregard any cultural considerationsD)To educate the client using written methods only.
Exam Review
- While assessing a patient, the nurse identifies a respiratory rate of 28 breaths per minute. Which action should the nurse prioritize?A)Assess for signs of hypoxia and respiratory distress.B)Administer supplemental oxygen immediately.C)Document the finding and notify the provider.D)Encourage the patient to breathe deeply and slowly.
- A patient is unable to reposition themselves and is at risk for pressure ulcers. Which bed position should a nurse prioritize to reduce this risk?A)SupineB)LateralC)TrendelenburgD)Prone
- The nurse observes a patient with a heart rate of 120 bpm and reports of dizziness. What is the nurse's next action?A)Administer IV fluids to stabilize heart rateB)Assess vital signs and check for underlying causes.C)Encourage the patient to left and restD)Notify the provider immediately.
- A patient with a contaminated abdominal wound after surgery is planned for delayed primary closure. Which of the following actions by the nurse is most appropriate to facilitate healing by tertiary intention?A)Leave the wound open for 5 to 10 days and then close with sutures.B)Immediately close the wound with sutures to prevent infection.C)Apply a hydrocolloid dressing to maintain a moist environment.D)Use mechanical debridement to remove necrotic tissue daily
Exam Review
- A nurse is assessing a patient with suspected oculomotor nerve (CN III) damage. Which finding would indicate an intact oculomotor nerve?A)Pupils constrict when looking at a close objectB)Absence of red reflexC)Pupils remain fixed and non-reactiveD)Pupils dilate in response to light
- A nurse witnesses a car accident and stops to assist the injured individuals. Under the Good Samaritan laws, what action is the nurse protected for?A)Administering medication from the nurse's personal supply.B)Performing CPR on an unconscious victimC)Providing a ride to the hospital for the victim.D)Offering legal advice to the victim regarding the accident.
- A patient presents to the emergency department with acute respiratory distress and a high fever. Which of the following should the nurse prioritize?A)Administering antipyretics immediately.B)Taking a detailed medical history.C)Administering intravenous fluids.D)initiating oxygen therapy.
- A nursing student is caring for a newborn who wakes up frequently at night. What is the best action to ensure restorative sleep while addressing the baby's needs?A)Introduce a blanket and stuffed animal to comfort the babyB)Check for hunger, wet diaper, or cold and fix the issue quietly using minimal light and noise.C)Allow the baby to cry until they fall back asleep naturallyD)Keep the baby awake during the day to reduce nighttime waking
Exam Review
- A patient presents with a skin abrasion on the forearm. Which of the following interventions is most important to prevent infection?A)Apply a moisturizing cream immediately.B)Cover the abrasion with a dry, sterile bandage.C)Use a scented lotion to cover the abrasionD)Leave the abrasion open to air.
- A nurse is developing a plan of care for a patient admitted with pneumonia who has cultural dietary restrictions. What is the most appropriate action?A)Provide nutritional supplements instead of accommodating cultural preferences.B)Advise the patient to follow the hospital's standard meal planC)Request the patient to bring meals from home to avoid complicationsD)Collaborate with the dietary team to ensure meals align with the patient's cultural preferences
- A 60-year-old client with a surgical wound is showing signs of serous drainage. Which of the following should the nurse document about the drainage?A)Watery and clear or slightly yellowB)Pale and pinkC)Reddish and thickD)Thick, yellow, and foul-smelling
- When assessing a patient with dark skin tones for suspected deep tissue injury, what should the nurse prioritize?A)Checking for intact skin with a reddish-pink wound bedB)Palpating for changes in skin temperature and moisture.C)Noting slough or eschar over the wound bed.D)Inspecting for erythema around bony prominences
Exam Review
- A client expresses confusion about the risks of a procedure after the provider explained them. What should the nurse do next?A)Provide a detailed explanation of the risks to the clientB)Refer the client to a medical interpreter for clarificationC)Ask the client to sign the consent form and proceed with the procedure.D)Notify the provider and request further clarification for the client.
- What is the primary purpose of using the PICOT format in Evidence-Based Practice?A)To identify the strongest evidence available.B)To evaluate the effectiveness of clinical guidelinesC)To formulate a specific and clear research question.D)To disseminate research findings effectively.
- A nurse is assessing a client's blood pressure using the two-step method. Which error could lead to inaccurate readings?A)Allowing the client to talk during the measurement.B)Using a cuff that is too small for the client.C)Positioning the client's arm below heart level.D)Using the same arm repeatedly without a break
- Which bed position is most appropriate for a patient with respiratory distress to facilitate easier breathing?A)Fowler'sB)TrendelenburgC)ProneD)Supine
Exam Review
- A nurse is caring for a patient who values spiritual practices and requests time for prayer before receiving treatment. What is the most appropriate nursing intervention?A)Proceed with the procedure and apologize later for not accommodating the requestB)Allow the patient uninterrupted time for prayer and reschedule the procedure if necessary.C)Ask the chaplain to perform the prayer instead of the patient.D)Inform the patient that spiritual practices must be completed after the procedure.
- A nurse is assessing a client's risk for pressure injuries using the Braden Scale. The client is bedridden, has a poor appetite, and frequently slides down in bed. Which Braden Scale category should be prioritized to address immediate interventions?A)NutritionB)ActivityC)Sensory PerceptionD)Friction and Shear
- A nurse is working in a healthcare facility that uses critical pathways to manage patient care. Which action by the nurse demonstrates an understanding of when to deviate from the critical pathway?A)Following the pathway strictly, regardless of patient changesB)Adjusting the care plan when a patient's condition deteriorates unexpectedlyC)Documenting a pathway deviation only if it improves the patient's condition.D)Using the critical pathway as a rigid schedule for patient interventions.
- A client's oxygen saturation is measured at 90% on room air. What action should the nurse take first?A)Place the client in a prone position to improve oxygenationB)Notify the provider and prepare for intubationC)Increase oxygen via nasal cannula to 2 L/min.D)Verify the reading and assess for signs of respiratory distress.