NursGuru
    Login/Signup
    Review ModeExam ModePractice Mode

    Exam Review

    1. 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)
      How many popsicles are available.
      B)
      If the popsicles are completely frozen.
      C)
      The color and flavor of gelatin used.
      D)
      Whether they contain pulp or fruit.
    2. 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 require 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 ability to change the ostomy bag in two days.
      B)
      The client will adhere to the medication regimen after discharge.
      C)
      The client's breath sounds will be auscultated by the nurse every 4 hours.
      D)
      The client attempts to self administer insulin but is unable to perform injection.
      E)
      None
      F)
      None
    3. A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client's parents arrive and are asking questions about the client's laboratory results. Which response is best for the nurse to provide?
      A)
      "I'm sorry, but your child's medical Information is none of your business."
      B)
      "I can only give medical Information to your child because they are legally an adult."
      C)
      "The healthcare provider will share this information with you."
      D)
      "I can give you those results as soon as I get them back from the laboratory."
    4. 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)
      Impaired physical mobility.
      C)
      Risk for impaired skin integrity.
      D)
      Self care deficit.
    Page 1 of 13

    Exam Review

    1. 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)
      "I am sorry to disturb you at a difficult time. This can walt until later."
      B)
      “While touching the client's forearm, asks, "Would you like to talk about it?"
      C)
      "This is a bad time. I can see you are upset. I can come back later."
      D)
      “Gives the client a hug and says, "It is okay to cry when you are sad."
    2. The nurse is interviewing a client with lower abdominal pain and dysuria, and needs to question the client about sexual activity. Which approach is best for the nurse to use?
      A)
      Ask questions in a vague, non specific format.
      B)
      Get the most difficult questions over with first.
      C)
      Begin with questions that are less sensitive in nature.
      D)
      Share personal values to put the client at ease.
    3. The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client's attention on which focus?
      A)
      Positive external places.
      B)
      Emotional reflection.
      C)
      Motivational phrases.
      D)
      Tranquil sounds.
    4. 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)
      A well approximated Incision site.
      B)
      Erythema and serosanguineous exudate.
      C)
      Eschar and slough in the wound.
      D)
      Beefy red granulation tissue.
    Page 2 of 13

    Exam Review

    1. After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?
      A)
      Enter the occurrence after the 1400 notes and identify as "late entry".
      B)
      Request removal initiated by the Health Information Manager.
      C)
      Create an electronic correction after 1400 notes are officially unlocked.
      D)
      Make an electronic addendum following the 1400 documentation.
    2. The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?
      A)
      Turn the head to the right and left.
      B)
      Extend the arm at the side and rotate in circles.
      C)
      Bend the arm by flexing the ulnar to the humerus.
      D)
      Tilt the pelvis forwards and backwards.
    3. 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)
      Initiate the facility's restraint flow sheet.
      B)
      Ensure that the restraints are not too tight.
      C)
      Demonstrate proper securing of the restraints.
      D)
      Complete an adverse occurrence/incident report.
    4. The nurse is assessing a client who is having pain of the right upper abdominal area. To assess the quality of the client's abdominal pain, which approach should the nurse use?
      A)
      Provide a numeric pain scale.
      B)
      Observe body language and movement.
      C)
      Ask the client to describe the pain.
      D)
      Identify effective pain relief measures.
    Page 3 of 13

    Exam Review

    1. 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)
      Switch to a non-rebreather mask.
      B)
      Verify placement of pulse oximeter.
      C)
      Remove nasal cannula.
      D)
      Increase the oxygen to 3 L/minute.
    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)
      Inject In abdominal area at least 2 in (5.1 cm) from the umbilicus.
      B)
      Rotate injections between the abdomen and gluteal areas.
      C)
      Expel the air in the prefilled syringe prior to Injection.
      D)
      Massage the injection site to increase absorption.
    3. The healthcare provider prescribes a 24 hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?
      A)
      Begin the collection the next day.
      B)
      Start collecting the specimen with the next void.
      C)
      Observe the sample for sediment.
      D)
      Empty the sample into the 24 hour container.
    4. 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)
      Warn the colleague that copying health information is unlawful.
      B)
      Send an email to facility administrators reporting the action.
      C)
      Communicate the colleague's activities to the unit charge nurse.
      D)
      Dispose the copies and continue with client care assignments.
    Page 4 of 13

    Exam Review

    1. A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?
      A)
      Capillary refill of 2 seconds in the lower right foot.
      B)
      Basilar lung sounds that are diminished in the left lung.
      C)
      Contraction of the left pupil when light shines in the right eye.
      D)
      Active bowel sounds in the lower right quadrant.
    2. 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? Reference Range: Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]
      A)
      Assess strength of deep tendon reflexes.
      B)
      Determine apical pulse rate and rhythm.
      C)
      Compare muscle strength bilaterally.
      D)
      Observe color and amount of urine.
    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)
      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.
      B)
      Send the UAP to be fitted for a particulate filter mask Immediately so the UAP can provide care to this client.
      C)
      Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client.
      D)
      Before changing assignments, determine which staff members have fitted particulate filter masks.
    4. 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)
      Withdraw the medication into a syringe and label it with the client's name.
      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)
      Ask another nurse to witness the medication being discarded.
    Page 5 of 13

    Exam Review

    1. 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.
    2. 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)
      Provide a back rub at bedtime.
      B)
      Leave the door to the client's room open slightly.
      C)
      Apply wrist restraints to prevent wandering.
      D)
      Administer a PRN sedative prescription.
    3. The nurse is reviewing the admission assessment of a client with chronic pain. What Intervention(s) should the nurse Include in the client's plan of care? Select all that apply.
      A)
      Encourage Increased fluid intake and measure urinary output every 8 hours.
      B)
      Assist the client to ambulate as much as possible during waking hours.
      C)
      Determine client's subjective measure of pain using a numerical pain scale.
      D)
      Provide comfort measures such as topical warm application and tactile massage.
      E)
      Implement a 24 hour schedule of routine administration of prescribed analgesic.
    4. The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action Indicates that a UAP understands gloving procedures?
      A)
      Keeps a pair of gloves in uniform pocket.
      B)
      Uses sterile gloves when handling body fluids.
      C)
      Dons sterile gloves when caring for clients with HIV.
      D)
      Puts on new gloves when entering a client's room.
    Page 6 of 13