Exam Review

After suctioning a client who has an endotracheal tube, which assessment finding indicates to the nurse that the intervention was effective?
A)
Clear breath sounds on auscultation.
B)
Increased respiratory rate.
C)
Decreased oxygen saturation.
D)
Presence of wheezing.
The nurse is assessing a client who is admitted to the renal unit with suspected decreased renal perfusion. The nurse should plan to carefully monitor which parameter? Reference Range: Urine white blood cells (WBC) [0 to 4 WBC/low powered field (lpf)]
A)
Blood pressure of 100/80 mm Hg.
B)
Abdominal pulse noted on inspection.
C)
Urinalysis with 1 to 4 WBC/lpf.
D)
Urinary output of 30 mL/hour.
Which action should the nurse implement when inserting an indwelling catheter for an uncircumcised male client?
A)
Position the sterile field even with the nurse’s hips.
B)
Clean the urinary meatus before retracting the foreskin.
C)
Use a swab to wipe the meatus in backward strokes.
D)
Advance the catheter before inflating the balloon.
When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include?
A)
Eat a soft diet with increased intake of milk and milk products.
B)
Eat a high fiber diet and increase fluid intake.
C)
Have small frequent meals and sit up for at least two hours after meals.
D)
Eat a bland diet and avoid spicy foods.

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Exam Review

A client who has been hospitalized with an exacerbation of heart failure experiences severe dyspnea with activity and remains on bedrest. Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure ulcer?
A)
Thick, dry, and dark area on bilateral heels.
B)
Broken skin without evidence of undermining.
C)
Defined area of persistent redness over bone.
D)
Superficial sacral ulcer with defined margins.
A client with a history of atrial fibrillation is prescribed warfarin. The nurse notes the client’s INR is 4.8. Which action should the nurse take? Reference Range: INR [2.0 to 3.0 for atrial fibrillation].
A)
Administer the prescribed warfarin dose.
B)
Notify the healthcare provider immediately.
C)
Encourage increased intake of green leafy vegetables.
D)
Monitor for signs of bleeding every 8 hours.
Following a total thyroidectomy, the nurse plans to observe a client for complications. Which finding indicates that the client has developed a complication?
A)
Denies muscle spasms in extremities.
B)
Complains of back and joint tenderness and pain.
C)
Complains of muscle twitching in hands and feet.
D)
Diaphoretic, but denies any headache.
A client is admitted to the hospital with suicidal ideation. When completing the health history and admission assessment interview, which client comment is most important for the nurse to document?
A)
“I just feel like my life is filled with emptiness.”
B)
“My panic attacks happen once every month.”
C)
“I have three firearms locked in a safe at home.”
D)
“My daughter is the only reason I keep trying.”

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Exam Review

A client who had a radical neck dissection returns to the surgical unit with two surgical drains in the right side of the incision. One drain bulb is open and has minimal drainage. Which action should the nurse take to increase drainage into the drain?
A)
Place the client in a right lateral side-lying position and elevate the head of the bed.
B)
Compress the bulb with the tab open and then reinsert the tab into its opening.
C)
Irrigate the drain tubing with 1 mL of NS, then close the opening with its tab.
D)
Reinforce the incisional dressings and assess behind the neck for drainage.
At 0800, the practical nurse (PN) reports to the registered nurse (RN) that a client’s blood pressure is 140/90 mm Hg. When the RN arrives to administer the 0900 antihypertensive medication, the client is oriented but lethargic, pale, and diaphoretic. Which action should the RN implement first?
A)
Obtain another measurement of the client’s blood pressure.
B)
Determine what medications the client recently received.
C)
Administer the antihypertensive medication as prescribed.
D)
Consult with the PN about the client’s condition at 0800.
Which client’s laboratory value requires immediate intervention by a nurse? Reference Range: Hemoglobin (Hgb) [14 to 18 g/dL (8.7 to 11.2 mmol/L)]; Fasting Blood Glucose [70 to 110 mg/dL (3.9 to 6.1 mmol/L)]; Neutrophils (ANC) [55 to 70%: 2,500 to 8,000/mm3 (2.5 to 5.8 x109/L)]
A)
A client with pancreatitis who has a fasting glucose of 190 mg/dL (10.55 mmol/L) today and had 160 mg/dL (8.88 mmol/L) yesterday.
B)
A client with a gastrointestinal (GI) bleed who is receiving a blood transfusion and has a hemoglobin of 7.0 g/dL (4.34 mmol/L).
C)
A client with cancer who has an absolute neutrophil count (ANC) of less than 500/mm3 today and had 2,000/mm3 yesterday.
D)
A client with hepatitis who is jaundiced and has a bilirubin level that is 4 times the normal value.
An older male client reports nocturia with difficulty starting his urine stream. Which additional assessment should the nurse perform to obtain further data related to this information?
A)
Question the client about related symptoms.
B)
Palpate the inguinal area for a bulge.
C)
Inspect the urethral meatus for abnormalities.
D)
Observe the scrotum for swelling.

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Exam Review

Which client information indicates the need for the nurse to use the CAGE questionnaire during the admission interview?
A)
Reports difficulties with short-term memory since a traumatic brain injury.
B)
Describes self as a social drinker who drinks alcoholic beverages daily.
C)
Client’s medication history includes the frequent use of antidepressants.
D)
Medical history includes that the client was recently sexually assaulted.
The parents of a male infant newborn have signed an informed consent for circumcision. Which priority intervention should the nurse implement upon completion of the circumcision procedure?
A)
Give a PRN prescribed dose of liquid acetaminophen.
B)
Wrap the infant in a warm receiving blankets.
C)
Offer a pacifier dipped in glucose water.
D)
Place petrolatum applied gauze dressings on the circumcision site.
During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?
A)
Recently received an influenza immunization.
B)
Corticosteroid cream was applied to the eczema.
C)
A grandson and his new pet dog recently visited.
D)
An old friend with eczema came for a visit.
A client has begun a long-term maintenance therapy with lithium, which has a narrow therapeutic index. Which adverse effect is most important for the nurse to include in the teaching plan?
A)
Dependence.
B)
Interaction.
C)
Toxicity.
D)
Tolerance.

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Exam Review

Based on the capillary glucose measurement, a client is to receive 10 units of regular insulin. The client’s medication drawer contains one vial of a 70/30 mixture of regular insulin and isophane insulin. How should the nurse prepare the prescribed dose?
A)
Withhold the dose until insulin regular is available on the unit.
B)
Withdraw 10 units regular insulin from the 70/30 vial.
C)
Pull up 30 units from the 70/30 vial, but only administer one third.
D)
Obtain a new vial of regular insulin and withdraw 10 units.
The nurse is initiating a 24-hour urine collection for a client with an indwelling urinary catheter. After emptying all the urine from the collection bag, which action is most important for the nurse to implement?
A)
Start the collection time now and stop the collection the next day at the same time.
B)
Provide catheter care at the urinary site to prevent contamination of the specimens.
C)
Clamp the catheter to control urine flow during the collection period.
D)
Label the collection container with the client’s name and start time.
Which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers?
A)
Oatmeal, raisins, and fruit with skin.
B)
Potatoes, low-fat breads, and applesauce.
C)
Chicken, rice, and wheat products.
D)
Lean beef, salads, and baked potatoes.
Five months following treatment for Herpes zoster (shingles), an older adult client tells the home health nurse of continuing to experience pain where the rash occurred. Which action should the nurse implement?
A)
Complete an assessment of the client's pain.
B)
Determine if the client has had a shingles vaccination.
C)
Perform a complete mental status exam.
D)
Teach the client about phantom pain symptoms.

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Exam Review

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which statement by the client indicates understanding?
A)
Remember exercise will not affect blood glucose levels.
B)
Follow the individualized meal plan and avoid high fat diets.
C)
Soak feet daily in hot water no longer than 10 minutes.
D)
Keep any wounds covered with an antibiotic ointment.
After administering lisinopril, an angiotensin-converting enzyme (ACE) inhibitor, it is most important for the nurse to monitor which assessment finding?
A)
Serum potassium and skin turgor.
B)
Eosinophil count and constipation.
C)
Blood pressure and risk for falls.
D)
Heart rate and reports of nausea.
After a client voids, 150 mL of residual urine is measured. Which nursing problem should be included in this client’s plan of care?
A)
Imbalanced nutrition.
B)
Deficient fluid volume.
C)
Risk for infection.
D)
Urinary incontinence.
Which serum laboratory test is most important for the nurse to monitor when administering enoxaparin to a client?
A)
Protein and albumin.
B)
Complete blood count (CBC).
C)
BUN and creatinine.
D)
Electrolytes.

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