NursGuru
    Login/Signup
    Review ModeExam ModePractice Mode

    Exam Review

    1. A nurse is caring for a client in the intensive care unit. Exhibits Complete the diagram by specifying 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.
      ✓Administer diuretics as prescribed
      ✓Perform chest physiotherapy
      ✓Hospital-acquired pneumonia
      ✓Oxygen saturation
      ✓White blood cell count
      Actions to Take
      ✓Administer diuretics as prescribed
      ✕Increase oxygen flow rate
      ✓Perform chest physiotherapy
      ✕Administer bronchodilators as prescribed
      ✕Elevate the head of the bed
      Potential Conditions
      ✕Acute respiratory distress syndrome (ARDS)
      ✕Congestive heart failure exacerbation
      ✓Hospital-acquired pneumonia
      ✕Chronic obstructive pulmonary disease (COPD) exacerbation
      Parameters to Monitor
      ✓Oxygen saturation
      ✕Blood pressure
      ✕Respiratory rate
      ✓White blood cell count
      ✕Serum creatinine
    2. The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?
      A)
      Verify placement of pulse oximeter.
      B)
      Increase the oxygen to 3 L/minute.
      C)
      Remove nasal cannula.
      D)
      Switch to a non-rebreather mask.
    3. The nurse is caring for a client with type 2 diabetes mellitus who had surgery for a large bowel resection with a colostomy placement. The client has now developed hyperglycemia which requires self-injections of insulin after discharge. When designing the postoperative plan of care, which outcome statement should the nurse use?
      A)
      The client will demonstrate the ability to change the ostomy bag in two days.
      B)
      The client attempts to self-administer insulin but is unable to perform the injection.
      C)
      The client’s breath sounds will be auscultated by the nurse every 4 hours.
      D)
      The client will adhere to the medication regimen after discharge.
    4. When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?
      A)
      Assess strength of deep tendon reflexes.
      B)
      Determine apical pulse rate and rhythm.
      C)
      Observe color and amount of urine.
      D)
      Compare muscle strength bilaterally.
    Page 1 of 14

    Exam Review

    1. The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer. The UAP pulls the client’s auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?
      A)
      Advise the UAP to hold the thermometer securely in place for a full three minutes.
      B)
      Use positive reinforcement to affirm that the procedure is being performed correctly.
      C)
      Demonstrate the correct technique for pulling the client’s auricle down and back.
      D)
      Remind the UAP to lubricate the thermometer before gently inserting it in the ear.
    2. The nurse is teaching a client about the 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)
      Dons a face mask before administering the medication.
      C)
      Washes hands before handling the needle and syringe.
      D)
      Removes the needle before discarding used syringes.
    3. 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)
      Ask the healthcare provider for a mild sedative for bedtime.
      B)
      Take an afternoon nap to make up for missed sleep.
      C)
      Drink a mixture of warm water, whiskey, and honey at bedtime.
      D)
      Establish a regular time for going to bed and getting up.
      E)
      Avoid drinking caffeinated beverages late in the day.
    4. The healthcare provider prescribes streptomycin 200 mg IM every 12 hours. The vial is labeled, “Streptomycin 1 gram/25.”. How many milliliters should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)
      Correct Answer:5 mL
    Page 2 of 14

    Exam Review

    1. A nurse is reviewing a client’s laboratory results and notes a blood glucose result of 104 mg/dL (5.8 mmol/L). The reference range is 74 to 106 mg/dL (4.1 to 5.9 mmol/L). Which action should the nurse take?
      A)
      Place the client on contact precautions.
      B)
      Start a high-fiber diet.
      C)
      Administer an oral steroid.
      D)
      Make the client NPO.
    2. A nurse is reviewing a client’s orders and notes the following: Vital signs every 4 hours, regular diet, Cefazolin 1g IV every 8 hours for 5 days, Metformin 1,000 mg PO every 12 hours, and point of care blood glucose check every 4 hours. Which action should the nurse take?
      A)
      Place the client on contact precautions.
      B)
      Start a high-fiber diet.
      C)
      Administer an oral steroid.
      D)
      Make the client NPO.
    3. An unlicensed assistive personnel (UAP) is assigned to feed a client who has received a prescription to institute droplet precautions for a bacterial meningitis infection. The UAP requests a change in assignment, reporting having not yet been fitted for a particulate filter mask. Which action should the nurse take?
      A)
      Send the UAP to be fitted for a particulate filter mask immediately so the UAP can provide care to this client.
      B)
      Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client.
      C)
      Before changing assignments, determine which staff members have fitted particulate filter masks.
      D)
      Advise the UAP to wear a standard face mask to obtain vital signs, and then get fitted for a filter mask before providing personal care.
    4. What times should the nurse measure vital signs? Select all that apply.
      A)
      1500.
      B)
      1600.
      C)
      1800.
      D)
      1000.
      E)
      1200.
      F)
      0800.
      G)
      1400.
    Page 3 of 14

    Exam Review

    1. The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?
      A)
      Offering therapeutic support and comfort to a grieving family.
      B)
      Obtaining clarification from a client’s healthcare power-of-attorney.
      C)
      Reporting a change in a client’s condition to the healthcare provider.
      D)
      Completing discharge teaching to a client and family members.
    2. To assess the quality of the client’s abdominal pain, which approach should the nurse use?
      A)
      Provide a numeric pain scale.
      B)
      Ask the client to describe the pain.
      C)
      Observe body language and movement.
      D)
      Identify effective pain relief measures.
    3. 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)
      Administer PRN oral pain medication.
      B)
      Ask the client what is causing the grimacing.
      C)
      Monitor the client’s nonverbal behavior.
      D)
      Review the pain medications prescribed.
    4. What times should the nurse measure vital signs? Select all that apply.
      A)
      0800.
      B)
      1000.
      C)
      1200.
      D)
      1400.
      E)
      1600.
      F)
      1800.
      G)
      2000.
    Page 4 of 14

    Exam Review

    1. 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)
      Teach the client to shorten the stride to prevent falls.
      C)
      Initiate a fall risk protocol for the client.
      D)
      Record the client’s ability to perform ADLs safely.
    2. The nurse is teaching the client to self-administer a dose of low molecular weight heparin SUBQ. Which instruction should the nurse include?
      A)
      Expel the air in the prefilled syringe prior to injection.
      B)
      Rotate injections between the abdomen and gluteal areas.
      C)
      Massage the injection site to increase absorption.
      D)
      Inject in the abdominal area at least 2 inches (5.1 cm) from the umbilicus.
    3. A client voided clear, yellow urine.
      A)
      The client is dehydrated.
      B)
      The client has a urinary tract infection.
      C)
      The client has normal urine output.
      D)
      The client has kidney stones.
    4. Patient Data Exhibits Review H and P, nurse’s notes, flow sheet, laboratory values, orders, and imaging studies. What times should the nurse measure vital signs? Select all that apply.
      A)
      1500.
      B)
      1600.
      C)
      1800.
      D)
      1000.
      E)
      1200.
      F)
      0800.
      G)
      1400.
      H)
      2000.
    Page 5 of 14

    Exam Review

    1. 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 in the plan of care?
      A)
      Record the client’s daily weight.
      B)
      Maintain in high Fowler’s position.
      C)
      Keep mucous membranes moist.
      D)
      Report any change in urine color.
    2. A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?
      A)
      Remove dentures or other oral appliance.
      B)
      Elevate the head of the bed to a 45-degree angle.
      C)
      Apply the client’s positive airway pressure device.
      D)
      Put and lock the side rails in place.
    3. Patient Data History and Physical Nurses’ Notes Laboratory Results Imaging Studies Intake and Output (I&O) Urine Output Flow Sheet Orders 1400 600 mL Temperature 102°F (38.9°C) orally Review H and P, nurse’s notes, flow sheet, laboratory values, orders, and imaging studies. What times should the nurse measure vital signs? Select all that apply.
      A)
      1500.
      B)
      1600.
      C)
      1800.
      D)
      1000.
      E)
      1200.
      F)
      0800.
      G)
      1400.
      H)
      2000.
    4. A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?
      A)
      Active bowel sounds in the lower right quadrant.
      B)
      Contraction of the left pupil when light shines in the right eye.
      C)
      Basilar lung sounds that are diminished in the left lung.
      D)
      Capillary refill of 2 seconds in the lower right foot.
    Page 6 of 14