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    Exam Review

    1. A nurse is caring for a client who has early-stage Alzheimer's disease. In which of the following actions is the nurse acting as a client advocate?
      A)
      Requesting a referral for the client to attend reminiscence therapy sessions
      B)
      Performing an updated cognitive assessment on the client
      C)
      Providing assistance for the client when ambulating down the hall
      D)
      Reorienting the client several times throughout the day
    2. A nurse is preparing to transfer a client from the emergency department to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the background portion of the report?
      A)
      The client's vital signs
      B)
      The client's name
      C)
      The client's code status
      D)
      A prescribed consultation
    3. A charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take first?
      A)
      Provide coverage for the nurses' breaks
      B)
      Review facility policies for taking scheduled breaks
      C)
      Determine the reasons the nurses are not taking scheduled breaks
      D)
      Discuss time management strategies with the nurses
    4. A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the highest priority?
      A)
      A client who has peripheral vascular disease and has an absent pedal pulse in the right foot
      B)
      A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy
      C)
      A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38°C (101°F)
      D)
      A client who is postoperative following a laminectomy 12 hr ago and is unable to void
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    Exam Review

    1. A charge nurse on an obstetrical unit is preparing the shift assignment. Which of the following clients should be assigned to an RN who has floated from a medical-surgical unit?
      A)
      A multigravida client who has preeclampsia and is receiving misoprostol for induction of labor
      B)
      A client who has gestational diabetes and is receiving biweekly nonstress tests
      C)
      A client who is at 32 weeks of gestation and has premature rupture of membranes
      D)
      A primigravida client who is 1 day postoperative following a Cesarean section and has a PCA pump
    2. A pediatric nurse is caring for multiple clients and reviewing each of their care plans. Which of the following client care interventions requires revising?
      A)
      Administer a bronchodilator two times a day for a child who has cystic fibrosis.
      B)
      Check the neurovascular status every 4 hr of a child who had a hip spica cast placed 6 hr ago
      C)
      Maintain eye shields for a newborn receiving phototherapy for hyperbilirubinemia.
      D)
      Teach an adolescent who has an exacerbation of ulcerative colitis about a high-protein, low-fiber diet
    3. A nurse on a medical-surgical unit is delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel?
      A)
      Using a pain rating scale to monitor a client's pain level
      B)
      Instructing a client on self-administration of a tap water enema
      C)
      Performing a dressing change on a client's peripherally inserted central catheter
      D)
      Suctioning a client's long-term tracheostomy
    4. A nurse is assessing a client who had a stroke 2 days ago. Which of the following findings should the nurse identify as a need for a referral to speech-language pathology?
      A)
      Diminished hand-to-mouth coordination
      B)
      Altered level of consciousness
      C)
      Unilateral ptosis
      D)
      Impaired voluntary cough
    Page 2 of 15

    Exam Review

    1. A newly hired unlicensed assistive personnel (UAP) expresses fear to the charge nurse about collecting a sputum specimen from a client who is HIV positive. Which action should the charge nurse take first?
      A)
      Provide the UAP with the infection control policy.
      B)
      Offer to assist the UAP with the collection of the specimen.
      C)
      Determine the UAP's knowledge about HIV transmission.
      D)
      Demonstrate the proper use of personal protective equipment.
    2. A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately?
      A)
      Report of photophobia
      B)
      Increased temperature
      C)
      Decreased level of consciousness
      D)
      Generalized rash over trunk
    3. A nurse is teaching a newly licensed nurse about the role of nurses during a facility disaster. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
      A)
      "A nurse can recommend clients who are stable for discharge during a disaster."
      B)
      "A unit nurse has the authority to prescribe emergency medications during a disaster."
      C)
      "A nurse should communicate with the performance improvement committee during a disaster to improve client outcomes."
      D)
      "A unit nurse can provide information to the media during a disaster."
    4. A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of asthma. The parent states she is unable to afford the nebulizer prescribed for the child. Which of the following referrals should the nurse recommend?
      A)
      Pharmacist
      B)
      Child protective services
      C)
      Social worker
      D)
      Respiratory therapist
    Page 3 of 15

    Exam Review

    1. A nurse is providing an in-service about actions to take during a fire on the unit. Which of the following instructions should the nurse include?
      A)
      Move client care equipment into the hallway
      B)
      Use the fire extinguisher by aiming at the top of the flames
      C)
      Close the windows in client rooms
      D)
      Place wet towels at the base of doors
    2. A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in wound care procedure. Which of the following findings indicates wound healing?
      A)
      Erythema on the skin surrounding a client's wound
      B)
      Deep red color on the center of a client's wound
      C)
      Increase in serosanguineous exudate from a client's wound
      D)
      Inflammation noted on the tissue edges of a client's wound
    3. A nurse is caring for a client who has uterine prolapse. The provider has recommended a total abdominal hysterectomy, but the client tells the nurse that the surgery is not an option. Which of the following is an appropriate action for the nurse to take?
      A)
      Initiate a mental health consult to determine the client's reasons for refusing surgery.
      B)
      Provide the client with information on treatment options and outcomes.
      C)
      Discuss with the client her concerns regarding the procedure.
      D)
      Inform the client of the consequences of uterine prolapse and the need for intervention.
    4. A nurse is serving on a committee whose task is to plan cost-effective care at the facility. Which of the following client care tasks should the nurse recommend?
      A)
      Change total parenteral nutrition IV tubing every 48 hr.
      B)
      Change peripheral IV primary tubing every 96 hr.
      C)
      Replace peripheral IV solution bags every 96 hr.
      D)
      Replace total parenteral nutrition solution bags every 48 hr.
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    Exam Review

    1. A nurse enters a client's room and notices a small fire in the bathroom trash can. The nurse removes the client from the room. Which of the following actions should the nurse take next?
      A)
      Close the fire doors and the doors to the clients' rooms.
      B)
      Extinguish the fire,
      C)
      Activate the fire alarm
      D)
      Remove all clients from the unit.
    2. A nurse is providing care for a client who is receiving chemotherapy. Which of the following actions should the nurse take?
      A)
      Wear gloves when handling the client's bed linens
      B)
      Flush the client's urine down the toilet twice
      C)
      Dispose of the client's intravenous tubing in a regular trash can
      D)
      Wash the client's dishes with hot water and soap
    3. A triage nurse in an emergency department is caring for a group of clients. Which of the following clients should the nurse assess first?
      A)
      A client who has a closed femur fracture from a fall
      B)
      A client who has a superficial burn covering 10% of their total body surface area
      C)
      A client who is experiencing severe vomiting and diarrhea with tachycardia
      D)
      A client who is confused and has slurred speech
    4. A nurse is teaching a group of newly hired nurses about evidence-based practice. The nurse should include which of the following as the first step in the process?
      A)
      Evaluate the outcomes
      B)
      Implement the findings
      C)
      Formulate a question
      D)
      Search for evidence
    Page 5 of 15

    Exam Review

    1. A nurse is preparing a client for surgery. The client expresses concern that someone might steal her purse during the procedure. Which of the following actions should the nurse take?
      A)
      Offer to store the purse at the nurses' station.
      B)
      Tell the client to leave her purse in a drawer of the bedside table.
      C)
      Place the purse in the clothing bag with the client's other belongings.
      D)
      Offer to place the purse in the facility safe.
    2. A nurse is preparing to discharge a client who has end-stage heart failure. The client's partner tells the nurse she can no longer handle caring for the client. Which of the following actions should the nurse take?
      A)
      Contact the case manager to discuss discharge options.
      B)
      Request another family member assist the client's partner with care.
      C)
      Ask the provider to delay the client's discharge home for a few more days.
      D)
      Recommend the partner place the client in a long-term care facility.
    3. A charge nurse notices that staff nurses are having difficulty using new IV infusion pumps for medication administration. Which of the following is the priority action by the charge nurse?
      A)
      Assess the staff nurses' knowledge deficit.
      B)
      Demonstrate use of the pump during medication administration.
      C)
      Plan an -service education program on the unit.
      D)
      Pair an inexperienced nurse with an experienced nurse.
    4. A nurse is teaching a client who speaks a different language than the nurse about medications. Which of the following actions should the nurse take?
      A)
      Provide the client with written information in their spoken language.
      B)
      Speak very slowly during the teaching session.
      C)
      Use medical terminology while explaining the medications.
      D)
      Have the client's family member who is present interpret.
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