Exam Review
- A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?A)Elevate the head of bed 45 degrees.B)Review the advanced directive document.C)Irrigate the nasogastric tube with water.D)Perform oropharyngeal suctioning.
- A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?A)Apply wrist restraints to prevent wandering.B)Leave the door to the client's room open slightly.C)Administer a PRN sedative prescription.D)Provide a back rub at bedtime.
- The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?A)Determine the client's activity tolerance.B)Record the client's ability to perform ADLs safely.C)Teach the client to shorten the stride to prevent falls.D)Initiate a fall risk protocol for the client.
- The nurse is teaching the client to self administer a dose of low molecular weight heparin SUBQ. Which instruction should the nurse include?A)Massage the injection site to increase absorption.B)Rotate injections between the abdomen and gluteal areas.C)Expel the air in the prefilled syringe prior to injection.D)Inject in abdominal area at least 2 in (5.1 cm) from the umbilicus.
Exam Review
- A client with chronic fecal incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which intervention should the nurse implement?A)Encourage the use of incontinence briefs.B)Assist to a bedside commode 30 minutes after meals.C)Administer a glycerin suppository 15 minutes after meals.D)Insert a rectal tube at specified intervals.
- An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.(SATA)A)Establish a regular time for going to bed and getting up.B)Avoid drinking caffeinated beverages late in the day.C)Drink a mixture of warm water, whiskey, and honey at bedtime.D)Take an afternoon nap to make up for missed sleep.E)Ask the healthcare provider for a mild sedative for bedtime.
- The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a fort?A)Placing a client in restraints without having a healthcare provider's order.B)Administering the medication to a client behind a closed curtain.C)Informing a client that the medication being administered is a vitamin.D)Enlisting security personnel to assist with restraining the client.
- The nurse in a skilled nursing facility observes a colleague leaving printed electronic medical record (EMR) copies of a client unattended on a counter top. Which action should the nurse implement?A)Communicate the colleague's activities to the unit charge nurse.B)Send an email to facility administrators reporting the action.C)Warn the colleague that copying health information is unlawful.D)Dispose the copies and continue with client care assignments.
Exam Review
- The nurse enters a client's room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?A)"This is a bad time. I can see you are upset. I can come back later."B)"I am sorry to disturb you at a difficult time. This can wait until later."C)While touching the client's forearm, asks, "Would you like to talk about it?"D)Gives the client a hug and says, "It is okay to cry when you are sad."
- The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL. vial. Which action should the nurse perform with the remainder of the medication?A)Ask another nurse to witness the medication being discarded.B)Throw the vial into the trash in the presence of another nurse.C)Place the vial with the remainder of the medication into a locked drawer.D)Withdraw the medication into a syringe and label it with the client's
- The palliative care nurse receives a consult for a terminally ill client in the intensive care unit. The client is weak, mouth breathing. and refusing anything to eat or drink. Which intervention should the nurse include plan of care?A)Record the client's daily weight.B)Keep mucous membranes moist.C)Maintain in high Fowler's position.D)Report any change in urine color.
- The nurse is assessing a client who reports a 3 day history of vomiting and diarrhea and experiencing difficulty in tolerating oral fluids. Which urine specific gravity value would the nurse expect to see on initial testing? Reference Range: Urine Specific Gravity [1.005 to 1.03]A)1.025.B)1.035.C)1.015.D)1.005.
Exam Review
- The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?A)Completing discharge teaching to a client and family members.B)Offering therapeutic support and comfort to a grieving family.C)Reporting a change in a client's condition to the healthcare provider.D)Obtaining clarification from a client's healthcare power-of-attorney.
- The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?A)Puts on new gloves when entering a client's room.B)Dons sterile gloves when caring for clients with HIV.C)Uses sterile gloves when handling body fluids.D)Keeps a pair of gloves in uniform packet.
- The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?A)Review the pain medications prescribed.B)Ask the client what is causing the grimacing.C)Monitor the client's nonverbal behavior.D)Administer PRN oral pain medication.E)NoneF)None
- The nurse is teaching a client about use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?A)Wears gloves to dispose of the needle and syringe.B)Washes hands before handling the needle and syringe.C)Dons a face mask before administering the medication.D)Removes needle before discarding used syringes.
Exam Review
- A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours PO as needed for cough. The battle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)
- The nurse is caring for a client one week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly?A)Erythema and serosanguineous exudate.B)Eschar and slough in the wound.C)Beefy red granulation tissue.D)A well approximated incision site.
- 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)Complete an adverse occurrence/incident report.B)Demonstrate proper securing of the restraints.C)Ensure that the restraints are not too tight.D)Initiate the facility's restraint flow sheet.E)NoneF)None
- A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?A)If the popsicles are completely frozen.B)The color and flavor of gelatin used.C)How many popsicles are available.D)Whether they contain pulp or fruit.
Exam Review
- The healthcare provider prescribes streptomycin 200 mg IM every 12 hours. The vial is labeled, "Streptomycin 1 gram/2.5 mL." How many milliliters should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)
- The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?A)Risk for infection.B)Risk for impaired skin integrity.C)Impaired physical mobility.D)Self-care deficit.
- A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which response is best for the nurse to provide?A)"It is important to dress the right arm first."B)"Dressing must be a frustrating experience for you."C)"We will give you a class on dressing tomorrow."D)"This unit has a policy against staff harassment."
- A client with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage?A)Stress reduction.B)Smoking cessation.C)Regular exercise.D)Low fat diet.