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    Exam Review

    1. Patient data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
      ✓Create a toilet training program
      ✓Secure the call bell so it is within reach
      ✓Functional incontinence
      ✓Blood pressure
      ✓Skin integrity
      Actions to Take
      ✕Provide skin care
      ✕Collect urine for a urinalysis and culture
      ✕Place an indwelling catheter
      ✓Create a toilet training program
      ✓Secure the call bell so it is within reach
      Potential Conditions
      ✓Functional incontinence
      ✕Overflow urinary incontinence
      ✕Reflex urinary incontinence
      ✕Urge incontinence
      Parameters to Monitor
      ✓Blood pressure
      ✕Mobility
      ✕Pain
      ✓Skin integrity
      ✕Postvoid residual
    2. A client tells the nurse how they hate the way their boss orders them around and never listens to their suggestions. Which response is best for the nurse to provide?
      A)
      "Why do you allow your boss to get you so upset?"
      B)
      "How do you feel when your boss does not listen to your suggestions?"
      C)
      "Maybe you should use a different approach with your boss."
      D)
      "It must be difficult for you to work in a situation that makes you feel so unhappy."
    3. The nurse is teaching the unlicensed assistive personnel (UAP) about safety when caring for clients with limited movement. Which action by the UAP indicates to the nurse that the UAP understands the information?
      A)
      Consult the posted mobility algorithm for client transfers.
      B)
      Keep the feet together and bend at the waist when lifting.
      C)
      Use a pulling motion when transferring and moving a client.
      D)
      Avoid lifting more than 45 pounds (18 kg) independently.
    4. While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively. Which action should the nurse implement?
      A)
      Demonstrate the skill, speaking slowly and using simple terms.
      B)
      Reduce the stimuli in the area before continuing the teaching.
      C)
      Reassure the client that the skill is not difficult to learn.
      D)
      Provide the client with step-by-step written instructions.
    Page 1 of 14

    Exam Review

    1. The nurse is caring for a client who is overweight and easily becomes diaphoretic. In response to this finding, which assessment(s) should the nurse include while assisting the client with personal care? Select all that apply.
      (SATA)
      A)
      Check skin for unusual bruising
      B)
      Palpate mucus membranes for cracks.
      C)
      Observe skin under the breasts
      D)
      Assess skin folds of perineal area.
      E)
      Monitor color of nailbeds.
    2. To assess a client's dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes, but does not feel a pulsation. Which action should the nurse take next?
      A)
      Document in the nurses' notes that the dorsalis pedis pulse is not palpable.
      B)
      Reduce the amount of pressure being applied on the top of the foot.
      C)
      Obtain a doppler stethoscope to auscultate the pulse at the same site.
      D)
      Palpate the site on the inner side of the ankle below the medial malleolus.
    3. The healthcare provider prescribes digoxin elixir 125 mcg PO daily. The drug is available in a 60 mL bottle labeled, "Digoxin elixir 0.05 mg/mL. How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)
      Correct Answer:2.5 mL.
    4. A client is being admitted to the unit with a varicella zoster virus infection. Which room should the charge nurse assign to the client?
      A)
      A semiprivate room with a roommate who has the same diagnosis and airborne precautions
      B)
      A semiprivate room with a roommate who has the same diagnosis and contact precautions
      C)
      A private room with both standard and droplet precautions
      D)
      A private room with both contact and airborne precautions
    Page 2 of 14

    Exam Review

    1. A client requests heat therapy for lower back pain. Which action should the nurse take?
      A)
      Obtain a prescription for heat application.
      B)
      Use moist towel as a skin barrier.
      C)
      Assess skin every 30 minutes after application.
      D)
      Demonstrate use of temperature control.
    2. While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, solid, and light brown. Which action should the nurse implement?
      A)
      Contact the healthcare provider before obtaining the specimen.
      B)
      Obtain the specimen from the client's current bowel movement.
      C)
      Withhold specimen collection until tarry black stool is observed.
      D)
      Wait to obtain the specimen until observable blood is present.
    3. Patient Data Exhibits Which medication error prevention techniques would have helped to avoid this error? Select all that apply
      A)
      Do not allow other activity to interrupt medication administration
      B)
      Document all medication as soon as it is given
      C)
      Involve and educate clients in medication administration
      D)
      Use at least 2 client identifiers before administering a dose
      E)
      Question unusually large or small doses
      F)
      Double check all dosage calculations
    4. The nurse is planning care for the elimination needs of a group of clients. The nurse determines a bedpan will be needed for which client?
      A)
      An older adult with left sided weakness.
      B)
      An adult client with enuresis
      C)
      An adult client with polyuria.
      D)
      An older adult with a right hip fracture.
    Page 3 of 14

    Exam Review

    1. An adolescent is scheduled to receive a required immunization injection. The client reports being afraid of injections because "shots hurt.” Which action should the nurse take?
      A)
      Offer assurance that this particular immunization is less painful than imagined.
      B)
      Use distraction to redirect the client's attention while the nurse gives the injection.
      C)
      Review the importance of receiving the immunization as a protection from disease.
      D)
      Invite the client to use the syringe on a dummy before receiving the immunization.
    2. The nurse observes the unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is most important for the nurse to implement?
      A)
      Ensure that the restraints are not too tight.
      B)
      Demonstrate proper securing of the restraints.
      C)
      Complete an adverse occurrence incident report.
      D)
      Initiate the facility's restraint flow shoot.
    3. The nurse assesses a client who has a nasal cannula delivering oxygen at 2 liters/minute. To assess for skin damage related to the cannula, which areas should the nurse observe? Select all that apply.
      A)
      Tops of the ears.
      B)
      Bridge of the nose.
      C)
      Around the nostrils.
      D)
      Across the forehead.
      E)
      Over the cheeks.
    4. In planning the turning schedule for a bedfast client, it is most important for the nurse to consider which assessment finding?
      A)
      Warm, dry skin with a fever of 100.0° F (37.8° C)
      B)
      Braden risk assessment scale rating score of ten.
      C)
      4+ pitting edema of both lower extremities.
      D)
      Hypoactive bowel sounds with infrequent bowel movements.
    Page 4 of 14

    Exam Review

    1. The nurse is preparing a client for surgery and notices that the signed consent form has an error. The form states that the client is to have the left leg amputated. However, the client's right leg is marked for the surgery. The nurse administered the preoperative opioid medication 10 minutes ago and there are no family members present. Which action should the nurse implement?
      A)
      Have the client sign another form before surgery.
      B)
      Call the nearest relative to come in and sign a new form.
      C)
      Call the healthcare provider (HCP) to have the procedure rescheduled.
      D)
      Cross out the error and initial the consent form.
    2. The nurse in providing teaching to a client who receives a new medication prescription. Which action should the nurse use to evaluate the client's understanding?
      A)
      Inquire about frequency of administration.
      B)
      Recognize sources of confusion for the client.
      C)
      Ask the client for any additional questions.
      D)
      Demonstrate how the medication will be taken.
    3. Which assessment data reflects the need for the nurse to include the problem, "Risk for falls" in a client's plan of care?Reference Range:Hemoglobin [14 to 18 g/dL (140 to 180 g/L)
      A)
      Expressed feelings of depression
      B)
      Recent serum hemoglobin level of 16 g/dL (160 g/L).
      C)
      Opioid analgesic received one hour ago.
      D)
      Stooped posture with a steady gait.
    4. A client arrives to the clinic describing concerns to the nurse about mood swings, insomnia, and a lack of focus. Which information should the nurse obtain first?
      A)
      Onset of symptoms.
      B)
      Methods to cope with stress.
      C)
      Recent life changes.
      D)
      Aggravating factors.
    Page 5 of 14

    Exam Review

    1. The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the client's foot in a basin of warm water placed on the bed. Which action should the nurse take?
      A)
      Remind the UAP to dry between the client's toes completely.
      B)
      Advise the UAP that this procedure is damaging to the skin.
      C)
      Add skin cream to the basin of water while the foot is soaking.
      D)
      Remove the basin of water from the client's bed immediately.
    2. An older adult woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vaginal tear, which the client reports is likely to have occurred during unprotected sexual intercourse. Which content is most important for the nurse to include in this client's teaching plan?
      A)
      Methods used to practice safe sex.
      B)
      Information about alternative ways to express sexuality.
      C)
      Intercourse positions that can help prevent tears.
      D)
      The importance of using vaginal lubricants.
    3. The nurse is caring for a client in the postanesthesia care unit (PACU). To assess the quality of the client's pain, which approach should the nurse use?
      A)
      Provide a numeric pain scale.
      B)
      Observe body language and movement
      C)
      Identify effective pain relief measures.
      D)
      Ask the client to describe the pain.
    4. While measuring vital signs, the nurse observes that a client is using accessory neck muscles during respirations. Which follow- up action should the nurse take first?
      A)
      Determine pulse pressure.
      B)
      Check for neck vein distention.
      C)
      Auscultate heart sounds.
      D)
      Measure oxygen saturation
    Page 6 of 14