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    Exam Review

    1. A nurse is conducting several health assessments. Which action(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.
      (SATA)
      A)
      Completing a follow-up focused assessment
      B)
      Assessing a client's mental health status
      C)
      Obtaining a client's vital weight
      D)
      Obtaining a client's vital signs
      E)
      Assessing a client's medication history
    2. Which information documented by the nurse is considered objective data?
      A)
      The client states, "My headache is an 8 out of 10 and throbbing."
      B)
      The client verbalizes, "I have a headache because I have not slept."
      C)
      The caregiver expresses concern about their infant crying all night.”
      D)
      The client exhibits facial grimacing and guards a swollen right forearm.”
    3. A client presents to the emergency department experiencing chest pain. They state, "I cannot stay, I need to get home to feed my cats." The healthcare provider reviews the risks of the client leaving without further treatment, however, the healthcare provider respects the client's right to make their own decisions, and they leave without treatment. What ethical principle did the healthcare provider uphold?
      A)
      Beneficence
      B)
      Fidelity
      C)
      Veracity
      D)
      Autonomy
    4. Which example of documentation is the most accurate representation of assessment data from a SOAP note?
      A)
      Subjective: "The client seems happy today." Objective: "Vital signs within normal limits."
      B)
      Assessment: "Client is anxious." Plan: "Give client medication as needed."
      C)
      Assessment: "Client is noncompliant with medications." Plan: "Assess for medication side effects."
      D)
      Subjective: "The client reports pain in the right leg." Objective: "Right leg appears swollen and red."
    Page 1 of 15

    Exam Review

    1. A nurse is preparing to perform palpation during an abdominal assessment of a client. Which describes the purpose of using light palpation?
      A)
      It reduces the client's anxiety during the assessment
      B)
      It helps identify areas of tenderness and abnormalities
      C)
      It is the only technique used for abdominal assessment
      D)
      It allows for the assessment of the abdominal organs
    2. A nurse is documenting findings following the examination of a client. Which should the nurse include as part of the general survey?
      A)
      Allergy assessment
      B)
      Skin temperature and color
      C)
      Reason for seeking care
      D)
      Posture and speech
    3. The nurse is planning a health promotion program for a group of clients. What action should the nurse plan to take first when implementing this health promotion plan?
      A)
      Determine the health education needs of the group.
      B)
      Customize the program to the group's strengths.
      C)
      Evaluate the program's effectiveness.
      D)
      Identify strategies that will enhance the program.
    4. A nurse is conducting several health assessments. Which action(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.
      (SATA)
      A)
      Completing a follow-up focused assessment
      B)
      Assessing a client's mental health status
      C)
      Obtaining a client's vital weight
      D)
      Obtaining a client's vital signs
      E)
      Assessing a client's medication history
    Page 2 of 15

    Exam Review

    1. The nurse prepares to leave the room after completing a client assessment. What action(s) should a nurse plan to take to promote safety before leaving a client's room? Select all that apply.
      (SATA)
      A)
      Offer comfort measures to the client
      B)
      Verify that two bedside rails are raised
      C)
      Ensure the bed is in the lowest position
      D)
      Thank the client before leaving the room
      E)
      Check that the bed is in the locked position
    2. A nurse completes a client's health history and a genogram. What is the reason for the nurse to complete a genogram?
      A)
      To identify the client's potential risk of diseases.
      B)
      To document characteristics of presenting symptoms.
      C)
      To identify the family resources the client has available.
      D)
      To document vaccination and immunization history.
    3. Exhibits Review the electronic health record. Which finding(s) should the nurse identify as subjective data? Select all that apply.
      A)
      Rhinitis of right nare present.
      B)
      Pulse 110 bpm.
      C)
      Temperature 101.8 F (38.7 C).
      D)
      Reports tenderness during palpation of sinus cavities.
      E)
      Reports light sensitivity.
      F)
      Lymphadenopathy >2 cm.
      G)
      History of allergies to pollen, dust, animal dander.
      H)
      Right eye periorbital edema present.
    4. A nurse educates a client with limited English-speaking skills about their disease. What action should the nurse take to ensure the client is able to understand the teaching?
      A)
      Request that handouts be prepared for the client.
      B)
      Provide information with graphics and photographs.
      C)
      Ask a family member to translate instructions.
      D)
      Use a trained medical interpreter for translation.
    Page 3 of 15

    Exam Review

    1. The nurse is evaluating the client's assessment within their electronic health record. For each finding, click to specify whether the assessment finding was collected as part of the health history interview or the physical exam.
      A)
      Covid-19 vaccine received in 2020
      B)
      Cholecystectomy in 2017
      C)
      Nausea after meals
      D)
      Skin color is appropriate to ethnicity with pink undertones
      E)
      Headache, rated as a 4 on a 0-10 scale
      F)
      Blood pressure 112/76 mmHg
    2. The nurse is caring for a client who is of a different culture than that of the nurse. When the nurse begins the physical assessment, the client seems apprehensive. What action should the nurse take?
      A)
      Explain the parts of the assessment and ask permission to move forward
      B)
      Return at a later time to complete the physical assessment and interview
      C)
      Get a different nurse to complete the physical assessment and interview
      D)
      Continue with the physical assessment so the client can get treatment
    3. A nurse is preparing to collect health history data during a client's admission. Which question(s) should the nurse ask? Select all that apply.
      A)
      "Have you ever had any surgeries?"
      B)
      "What type of health insurance do you have?"
      C)
      "Have you ever smoked tobacco products?"
      D)
      "What illnesses did you have as a child?"
      E)
      "Have you had any reactions to your medications?"
    4. A nurse evaluates a client's understanding of why a medication reconciliation is performed upon admission to the hospital. Which statement made by the client indicates understanding?
      A)
      "It helps to determine the cost of my medications during my stay."
      B)
      "It is done to check if I have any allergies to the medications."
      C)
      "It is performed to see if I need any new medications prescribed."
      D)
      "It helps to reduce errors and promote safety during my stay."
    Page 4 of 15

    Exam Review

    1. A nurse is collecting a complete health history of a client. What is the purpose of the review of systems?
      A)
      Ask about the client's ability to perform daily tasks
      B)
      Perform a physical assessment
      C)
      Talk about the laboratory test results for each system
      D)
      Review each body part to ask the client about experiences or issues
    2. A nurse is caring for a newly admitted client. Which should the nurse include in the assessment phase of the nursing process?
      A)
      Identify the needed nursing actions to address the client's health problem.
      B)
      Interview the client about current and past health history.
      C)
      Measure the success of the care goals.
      D)
      Develop the expected outcome with the client.
    3. Which step of the nursing process is the nurse performing when educating a client about how to do a blood glucose check?
      A)
      Evaluation
      B)
      Planning
      C)
      Implementation
      D)
      Assessment
    4. What is the purpose of clustering clues during the critical thinking process?
      A)
      Identifying relationships among signs and symptoms
      B)
      Identify the client's healthcare attitudes
      C)
      Validating data to tell the healthcare provider
      D)
      Identifying gaps in the client's care for the care plan
    Page 5 of 15

    Exam Review

    1. Which is included in the general survey?
      A)
      Measuring the client's vital signs
      B)
      Observing the client's body stature
      C)
      Auscultating lung sounds
      D)
      Prioritizing client's needs
    2. A nurse is performing the behavioral assessment of the general survey. Which assessment should the nurse include related to behavior?
      A)
      Mood
      B)
      Age
      C)
      Posture
      D)
      Gait
    3. A nurse is providing education to a group of new nurses about maintaining confidentiality in nursing documentation. Which statement by a new nurse indicates a need for further teaching?
      A)
      "It's important to store client charts and documents in a secure location when not in use."
      B)
      "I can share a client's medical information with my friends as long as I don't disclose the client's name."
      C)
      "We should use client identifiers such as full name and date of birth on every page of the client's chart."
      D)
      "When discussing client information, we should use private and secure areas to prevent unauthorized access."
    4. What assessment(s) are included in the physical appearance portion of the general survey? Select all that apply.
      A)
      Behavior
      B)
      Level of consciousness
      C)
      Range of motion
      D)
      Facial features
      E)
      Sexual development
    Page 6 of 15