NursGuru

    Exam Review

    1. The nurse is taking vital signs on a patient with a fractured femur. The blood pressure reading is 150/96. The patient does not have a history of hypertension. What action should the nurse take next?
      A)
      Check the blood pressure in 90 minutes.
      B)
      Call the health care provider and request an anti-anxiety medication.
      C)
      Call the health care provider and request an antihypertensive.
      D)
      Ask the patient if she is having pain.
    2. Which laboratory result indicates the presence of malnutrition?
      A)
      Hemoglobin (Hgb) 11.3 g/dL
      B)
      Creatinine 1.9 mg/dL
      C)
      Hematocrit (Hct) 56%
      D)
      Serum albumin 2.8 g/dL
    3. Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 bpm. The nurse notifies the health care provider because the client is exhibiting signs of:
      A)
      Hypertension.
      B)
      A dysrhythmia.
      C)
      Tachycardia.
      D)
      Bradycardia.
    4. The nurse is evaluating outcomes for a patient with insomnia. Which key principle will the nurse consider during this process?
      A)
      Effective interventions are the best evaluators of sleep.
      B)
      The patient is the best evaluator of sleep.
      C)
      Observations of the patient are the best evaluators of sleep.
      D)
      The nurse is the best evaluator of sleep.

    Exam Review

    1. Precise wound documentation contributes to which of the below elements? (Select all that apply)
      (SATA)
      A)
      Continuity of Care
      B)
      Accurate Evaluation of Care
      C)
      Appropriate changes in wound
      D)
      Closed drainage system
    2. A nurse is caring for a patient who is experiencing fluid volume deficit. Which signs should the nurse document as part of the assessment which correlates with a fluid volume deficit? (Select all that apply)
      (SATA)
      A)
      Reduced skin turgor
      B)
      Decreased blood pressure
      C)
      Increased urine output
      D)
      Increased heart rate
      E)
      Dry mouth, dry skin
    3. Before administering a cleansing enema to an 80-year-old patient, the patient says, “I don’t think I will be able to hold the enema.” Which is the next priority nursing action?
      A)
      Assisting the patient to the bedside commode and administering the enema
      B)
      Inserting a rectal plug to contain the enema solution after administering
      C)
      Rolling the patient into right-lying Sims’ position
      D)
      Positioning the patient in the dorsal recumbent position on a bedpan
    4. While reading a physician’s note, a student learns the patient is having hypoxia. Which abnormal patient assessments would a student expect to find with hypoxia?
      A)
      Dyspnea, tachycardia, cyanosis
      B)
      Diarrhea, flatulence, decreased skin turgor
      C)
      Hypotension, reddened skin, edema
      D)
      Abdominal pain, hyperthermia, dry skin

    Exam Review

    1. The nurse is assessing a client with dark skin for the presence of a Stage I pressure ulcer. Which is the best approach to making this assessment?
      A)
      Use a fluorescent light source to assess the skin.
      B)
      Inspect the skin only if the Braden score indicates a risk.
      C)
      Avoid touching the skin during inspection.
      D)
      Look for skin color that is darker than surrounding areas.
    2. Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use?
      A)
      Ask the client's full name and date of birth.
      B)
      Verify the client's room number.
      C)
      Check the client's name on the medication administration record (MAR).
      D)
      Ask a family member to verify the client's identity.
    3. A patient has a hemoglobin of 7.1 g/dL. The nurse understands that anemia is likely to result in which of the following?
      A)
      Decreased lung compliance.
      B)
      Hypovolemia.
      C)
      Impaired ventilation.
      D)
      Hypoxemia.
    4. Which is an example of nonmaleficence?
      A)
      Protecting clients from a health care provider under the influence of an opioid.
      B)
      Performing dressing changes to promote wound healing.
      C)
      Providing emotional support to clients who are anxious.
      D)
      Administering pain medications to a client in pain.

    Exam Review

    1. In providing diet education for a patient on a low-fat diet, which information is important for the nurse to share?
      A)
      Fats are found mostly in animal sources.
      B)
      Unsaturated fats are found mostly in animal sources.
      C)
      Trans fat should be less than 7% of the total calories.
      D)
      Polyunsaturated fats should be less than 7% of the total calories.
    2. The client's plan of care is created by the nurse using which guideline for nursing practice?
      A)
      Nursing process
      B)
      Nursing’s Social Policy Statement
      C)
      Nurse Practice Act
      D)
      ANA Standards of Nursing Practice
    3. While caring for a client near end of life, a nurse talks to the client. An unlicensed assistive personnel asks why the nurse is talking to someone who is dying. Which response is accurate?
      A)
      It makes me feel better to talk to my clients.
      B)
      I do this so I will not be so afraid the client will die.
      C)
      I believe the client can hear me as long as the client is alive.
      D)
      I do not know; the client’s family asked me to do this.
    4. Based on an established plan of care, a nurse turns a client every 2 hours. Which part of the nursing process is the nurse using?
      A)
      Assessing
      B)
      Planning
      C)
      Implementing
      D)
      Evaluating

    Exam Review

    1. The patient complains of abdominal pain. Before palpating the abdomen, which action should the nurse perform?
      A)
      Don sterile gloves.
      B)
      Elevate the patient’s head.
      C)
      Percuss all four quandrants.
      D)
      Auscultate the bowel sounds.
    2. A nurse is assessing a client who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would the client most likely exhibit?
      A)
      Bradycardia
      B)
      Tachycardia
      C)
      Dysrhythmia
      D)
      Bigeminal
    3. A registered nurse assigns the task of tracheostomy suctioning of a client to the Licensed Practical Nurse (LPN). The LPN informs the nurse that the LPN has never performed this procedure on a client. Which of the following is the most appropriate response from the registered nurse?
      A)
      You are through with your theory class, so you should know.
      B)
      Ask for help from a nurse who knows how to perform the procedure.
      C)
      Review the procedure in the manual and act accordingly.
      D)
      I will assist you in performing the procedure on the client.
    4. The nurse is caring for a patient diagnosed with tuberculosis in a hospital setting and must initiate airborne precautions. Which of the following is true related to airborne precautions?
      A)
      The patient can share a hospital room with a roommate.
      B)
      Use of a mask is not required.
      C)
      Patients will be in a positive pressure airflow room.
      D)
      Patients will be in a negative pressure airflow exchange room.

    Exam Review

    1. A nurse is educating a postoperative client on how to use an incentive spirometer. What is an accurate statement that should be included in the education plan?
      A)
      Encourage the client to perform incentive spirometry 2 to 3 times every 1 to 2 hours, if possible.
      B)
      Instruct the client to inhale slowly and as deeply as possible through the mouthpiece, without using the nose.
      C)
      Instruct the client to inhale normally and then place the lips securely around the mouthpiece.
      D)
      When the client cannot inhale anymore, the client should hold his breath and count to 10.
    2. The nurse is providing preoperative teaching to a patient to have an operation on their colon for cancer. The nurse should take which of the following actions regarding informed consent?
      A)
      Ensure the patient has received all necessary information about the procedure.
      B)
      Make sure the client is competent to give consent.
      C)
      Give a complete description of the procedure.
      D)
      Witness the informed consent.
      E)
      Research a non-surgical alternative treatment for colon cancer.
    3. The nurse is assessing the patient’s respirations. Which action by the nurse is most appropriate?
      A)
      Do not touch the patient until the assessment is completed.
      B)
      Inform the patient that she is counting respirations.
      C)
      Obtain the rate without the patient knowing.
      D)
      Estimate respirations.
    4. A nurse is going to teach a patient about hypertension. Which action should the nurse implement first?
      A)
      Set mutual goals for knowledge of hypertension.
      B)
      Teach what the patient wants to know about hypertension.
      C)
      Assess what the patient already knows about hypertension.
      D)
      Evaluate the outcomes of patient education for hypertension.