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    Exam Review

    1. A nurse is planning care for a client who has sciatica and a prescription for a transcutaneous electrical nerve stimulation (TENS) unit. Which of the following referrals should the nurse anticipate for this client?
      A)
      Occupational therapist
      B)
      Physical therapist
      C)
      Acupuncturist
      D)
      Chiropractor
    2. A nurse is documenting admission data for a client in an acute care facility. Which of the following actions should the nurse take?
      A)
      Begin charting with an evaluation of the data.
      B)
      Document the client’s vital signs obtained by an assistive personnel.
      C)
      Chart a summary of the data at the change of shift.
      D)
      Note whether the client has a living will.
    3. A nurse is creating an incident report due to an accidental omission of a client's dressing change during the previous shift. Which of the following statements should the nurse document on the incident report form?
      A)
      Prescribed dressing change was accidentally omitted during the previous shift.
      B)
      A nurse accidentally omitted a prescribed dressing change. Will notify the provider tomorrow.
      C)
      Incident report completed. A copy will be placed in the client's medical record.
      D)
      Unable to complete a prescribed dressing change. However, dressing did not appear to be soiled.
    4. A nurse is providing discharge teaching to a client who has a new ostomy. Which of the following instructions should the nurse include?
      A)
      Apply sterile gloves when changing your ostomy pouch.
      B)
      Empty your ostomy pouch when it is half full.
      C)
      Use a moisturizing soap to cleanse your stoma.
      D)
      Notify the provider if your stoma becomes pink and moist.
    Page 1 of 16

    Exam Review

    1. A nurse is teaching a client about using transdermal scopolamine to treat motion sickness. Which of the following instructions should the nurse include?
      A)
      Apply the patch prior to traveling.
      B)
      Replace a dislodged patch onto the same location.
      C)
      Store unused patches in the refrigerator.
      D)
      Place the patch on your upper arm.
    2. A nurse is teaching the guardian of a newborn about car seat safety. Which of the following statements by the guardian indicates an understanding of the teaching?
      A)
      I will place the retainer clip on my baby's upper abdomen.
      B)
      I will turn the car seat forward facing when my baby is 1 year old.
      C)
      I will position the shoulder harness straps 3 inches above my baby's shoulders.
      D)
      I will position my baby at a 45-degree angle in the car seat.
    3. A nurse is teaching the guardian of a newborn about car seat safety. Which of the following statements by the guardian indicates an understanding of the teaching?
      A)
      I will place the retainer clip on my baby's upper abdomen.
      B)
      I will turn the car seat forward facing when my baby is 1 year old.
      C)
      I will position the shoulder harness straps 3 inches above my baby's shoulders.
      D)
      I will position my baby at a 45-degree angle in the car seat.
      E)
      None
      F)
      None
    4. A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an indication of paralytic ileus?
      A)
      Dizziness.
      B)
      Watery stool.
      C)
      Abdominal distention.
      D)
      Oliguria.
    Page 2 of 16

    Exam Review

    1. A community health nurse is planning an educational program on Lyme disease for the general public. Which of the following statements should the nurse include in the program?
      A)
      Remove embedded ticks by squeezing the body with tweezers.
      B)
      If bitten by a tick, testing for Lyme disease should occur within 2 weeks.
      C)
      Symptoms of Lyme disease appear 2 days after being bitten by an infected tick.
      D)
      Use a product with DEET on your skin and clothes when you are walking in a wooded area.
    2. A nurse is reviewing the medical record of a client who has a prescription for misoprostol for induction of labor. Which of the following findings is a contraindication for administration of this medication?
      A)
      Preeclampsia.
      B)
      Transverse fetal lie.
      C)
      Intrauterine growth restriction.
      D)
      Postterm pregnancy.
    3. While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm on the ventilator sounds. Which of the following actions should the nurse take?
      A)
      Suction the client's airway.
      B)
      Request insertion of a tracheostomy tube.
      C)
      Look for a leak in the tube's cuff.
      D)
      Tighten the tubing connections.
    4. A nurse is teaching a client who has major depressive disorder about what to expect when undergoing electroconvulsive therapy. Which of the following information should the nurse give the client?
      A)
      You can expect to feel some pulsations in your neck during the procedure.
      B)
      You might feel a bit confused for a few hours after the procedure.
      C)
      You’ll wake up about 30 minutes after the procedure.
      D)
      You might notice some changes in your voice after the procedure.
    Page 3 of 16

    Exam Review

    1. A nurse at a health department is providing anticipatory guidance to the parent of a 1-month-old infant. The nurse should inform the parent that the infant should receive which of the following immunizations at the age of 2 months?a) Hepatitis
      A)
      Hepatitis A.
      B)
      Varicella.
      C)
      Rotavirus.
      D)
      Influenza.
    2. A nurse is teaching a client who has a new prescription for metformin extended-release tablets. Which of the following statements by the client indicates an understanding of the teaching?
      A)
      I will avoid crushing this medication.
      B)
      I will expect to gain weight.
      C)
      I will take the medication in the morning.
      D)
      I will take the medication on an empty stomach.
    3. A nurse is caring for a client who is 2 days postpartum. Which of the following findings should the nurse report to the provider?
      A)
      4+ deep-tendon reflexes.
      B)
      Urine output 2,500 mL/day.
      C)
      Scant lochia rubra with a few small clots.
      D)
      Bilateral ankle edema.
    4. A charge nurse is observing an assistive personnel perform delegated tasks. Which of the following actions by the AP requires the charge nurse to intervene?
      A)
      Emptying an indwelling urinary catheter bag for a client while wearing clean gloves.
      B)
      Performing a simple dressing change on a client’s foot.
      C)
      Providing postmortem care for a client who has recently died.
      D)
      Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile.
    Page 4 of 16

    Exam Review

    1. A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The client reports chills, headache, low-back pain, and a feeling of “tightness” in their chest. The nurse should identify that the client has developed which of the following types of transfusion reactions?
      A)
      Bacterial.
      B)
      Allergic.
      C)
      Acute hemolytic.
      D)
      Febrile nonhemolytic.
    2. A nurse is assessing a client who is taking digoxin to treat chronic heart failure. Which of the following findings should indicate to the nurse that the client is developing digoxin toxicity?
      A)
      Insomnia.
      B)
      Blurred vision.
      C)
      Tachycardia.
      D)
      Hearing loss.
    3. A nurse is developing a plan of care for a child who is in skeletal traction following a femur fracture. Which of the following actions should the nurse include in the plan?
      A)
      Monitor the neurovascular status of the child’s lower extremities every 12 hours.
      B)
      Educate the child’s guardians about pin site care prior to discharge.
      C)
      Have the child rate their level of pain every 8 hours.
      D)
      Lift the traction weights when repositioning the child in bed.
    4. A nurse is planning postoperative care for a client who is scheduled for a thoracotomy with chest tube placement. Which of the following pieces of equipment should the nurse plan to have at the client’s bedside?
      A)
      Tracheostomy tray.
      B)
      Wire cutters.
      C)
      Montgomery straps.
      D)
      Padded clamp.
    Page 5 of 16

    Exam Review

    1. A nurse is planning assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply)
      A)
      Obtain a client’s vital signs every 4 hours.
      B)
      Insert an NG tube for a client who requires enteral feedings.
      C)
      Record a client’s intake after each meal.
      D)
      Transfer a client to physical therapy.
      E)
      Instruct a client on the use of an incentive spirometer.
    2. A nurse is planning care for a client who is undergoing brachytherapy with a low-dose radiation implant for treatment of prostate cancer. Which of the following interventions should the nurse include in the client’s plan of care?
      A)
      Limit each of the client’s visitors to 2 hours per day.
      B)
      Attach a dosimeter to the client’s gown.
      C)
      Instruct visitors to stay 1 meter (3.3 feet) away from the client.
      D)
      Strain the client’s urine.
    3. A school nurse is using the Weber’s test to check a child’s hearing acuity. Which of the following actions should the nurse take?
      A)
      Place a vibrating tuning fork on the top of the child’s head.
      B)
      Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child’s ears.
      C)
      Measure the amount of time the child can hear the sound.
      D)
      Obtain a tympanogram reading prior to initiating the test.
    4. A nurse is assessing a client who is in mechanical restraints after hitting a staff member. Which of the following findings indicates that the nurse should discontinue the restraints?
      A)
      The client reports that the restraints are too tight.
      B)
      The client is able to calmly follow commands.
      C)
      The client has been in the restraints for 4 hours.
      D)
      The client can explain the reasons for their behavior.
    Page 6 of 16