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    Exam Review

    1. Which term describes the condition of a patient who requires an increase in opioid pain medication dosage to maintain adequate analgesia?
      A)
      Drug tolerance
      B)
      Physical dependence
      C)
      Psychological dependence
      D)
      Pseudoaddiction
    2. The nurse is having difficulty managing time while caring for a group of patients with complex needs. Medications are behind schedule and several nursing procedures have not been performed. How should the nurse resolve the time management issue? Place the following steps in order.
      A)
      Identify which nursing interventions are a priority.
      1
      B)
      Identify which interventions can be delegated to other members of the health care team.
      2
      C)
      Delegate the appropriate interventions to other members of the health care team.
      3
      D)
      Evaluate that the nursing interventions were completed successfully.
      4
    3. Which patient has the greatest risk for a problem with transporting oxygen to the peripheral tissues from the lungs?
      A)
      Fractured ribs
      B)
      Ear infection
      C)
      Anemia
      D)
      Tumor of the medulla
    4. A nurse is providing teaching to a patient scheduled for abdominal surgery. After discussing the use of the incentive spirometer with the patient, they ask the patient to demonstrate how to use the device. Which action by the patient demonstrates that the patient understood the teaching?
      A)
      The patient inhales and then places the mouthpiece into their mouth and exhales into the mouthpiece.
      B)
      The patient inhales into the mouthpiece quickly and shallowly.
      C)
      The patient places the mouthpiece into their mouth and inhales slowly until they can no longer inhale, holds breath for 6 seconds and then exhales.
      D)
      The patient slowly inhales and exhales into the mouthpiece multiple times and then holds their breath for 2 seconds.
    Page 1 of 11

    Exam Review

    1. The nurse is caring for a patient admitted to the hospital with chronic lung disease. He remains short of breath and will need oxygen at home as well as adjustments in the home to accommodate the large number of steps to his bedroom. The nurse understands that s/he must coordinate discharge care with:
      A)
      Occupational Therapy
      B)
      Care Coordinator Social Worker
      C)
      Inpatient Hospice Care
      D)
      Physical Therapy
    2. A 45-year-old patient who reports pain in the foot that moves up along the calf says: "My right foot feels like it is on fire." The patient reports that the pain started yesterday, and he has no prior history of injury or falls. Which components of pain assessment has the patient reported?
      A)
      Exacerbation, with associated signs and symptoms.
      B)
      Aggravating and alleviating factors.
      C)
      Intensity, temporal characteristics, and functional impact.
      D)
      Location, quality, and onset.
    3. A patient with limited mobility requires a thorough skin assessment every shift. As the nurse performing this assessment, which of the following areas would be of fewest priority to observe?
      A)
      Heels of the feet
      B)
      Sacral area
      C)
      Palms of the hands
      D)
      Under the folds of excess skin (breast, stomach)
    4. While performing a bed bath, the nurse notes a wound on the patient's sacrum. The wound presents as a shallow open wound with a red-pink wound bed and partial thickness skin loss. What is the correct stage of this wound?
      A)
      Deep tissue pressure injury
      B)
      Stage 3 pressure injury
      C)
      Stage 2 pressure injury
      D)
      Stage 1 pressure injury
    Page 2 of 11

    Exam Review

    1. While ambulating a patient one day post-surgery, the patient turns pale and states, “I feel dizzy.” The best action by the nurse is:
      A)
      Lean the patient up against the wall and go find help.
      B)
      Sit the patient in a nearby chair and take his/her vital signs.
      C)
      Instruct the patient to lean up against the wall and breathe.
      D)
      Return the patient to his/her room immediately.
    2. A nurse needs to move a patient up in bed. Which of the following body mechanic principles should the nurse observe to prevent injury?
      A)
      Raise the side rails and make sure the wheels are locked.
      B)
      Lower the bed to the lowest position prior to lifting the patient.
      C)
      Request assistance from other staff members.
      D)
      Raise the head of the bed before moving the patient up to aid in the patient’s breathing.
    3. Why is it important to obtain information from a patient related to the use of herbal supplements during a nursing assessment?
      A)
      Some herbs or supplements require a special diet.
      B)
      Some herbs or supplements may interact with a patient’s prescribed medications.
      C)
      Nurses have special knowledge related to the use of herbs and supplements.
      D)
      The herb or supplement may need to be acquired from another country.
    4. Upon responding to the patient’s call bell, the nurse discovers the patient’s wound has dehisced. Initial nursing management includes calling the health care provider and:
      A)
      Closing the wound with reinforced adhesive skin closures.
      B)
      Holding the wound together until the health care provider arrives.
      C)
      Pouring sterile hydrogen peroxide into the abdominal cavity and packing with gauze.
      D)
      Covering the wound with sterile gauze moistened with sterile saline.
    Page 3 of 11

    Exam Review

    1. A registered nurse (RN) is delegating a task to the unlicensed assistive personnel (UAP) that involves bathing a critically ill, unstable patient. Which of the five rights of delegation is being violated in this situation?
      A)
      Direction
      B)
      Task
      C)
      Evaluation
      D)
      Circumstance
    2. A patient has just been transferred from the hospital to a long-term care facility in the community. The patient’s pastor calls the nurse to get information for the patient’s address and phone number at the long-term care facility. What is the best response of the nurse?
      A)
      “I am going to transfer your call to our nursing supervisor.”
      B)
      “Let me get that information for you.”
      C)
      “You will need to contact the patient or their family for that information.”
      D)
      “That information is only available from the patient’s physician.”
    3. The patient states they are having difficulty swallowing. Which nursing intervention is priority to prevent aspiration?
      A)
      Provide only thin liquid options to the patient.
      B)
      Assist the patient with feeding and observe swallowing ability.
      C)
      Ensure that the head of the bed is at 30 degrees while eating.
      D)
      Provide large meals twice per day.
    4. A nurse researching a diet for a patient with diabetes includes foods that supply energy to the body. Which are classes of nutrients that supply this energy? Select all that apply.
      A)
      Proteins
      B)
      Fats
      C)
      Vitamins
      D)
      Carbohydrates
      E)
      Minerals
    Page 4 of 11

    Exam Review

    1. A 65-year-old patient with pneumonia has been on bedrest for two days. New orders were written for the patient to ambulate BID with assistance. The patient's vital signs are: T-98.4, HR-78, Resp-18, BP-90/70, O₂ saturation 94%, Pain-0/10. In preparing the patient to ambulate safely, which action should be the priority?
      A)
      Allow the patient to sit up and let feet dangle on the side of the bed for several minutes.
      B)
      Place soft booties that the patient brought from home on the patient's feet.
      C)
      Give the patient 150 mL bolus of IV fluids prior to discontinuing the IV.
      D)
      Give the patient PRN pain medications as ordered from the Medication Administration Record.
    2. Which data entry follows the recommended guidelines for documenting data?
      A)
      "Following oxygen administration, vital signs returned to baseline."
      B)
      "Patient's kidneys are producing sufficient amount of measured urine."
      C)
      "Patient is overwhelmed by the diagnosis of pancreatic cancer."
      D)
      "Patient reported about the quality of the nursing care provided on previous shift."
    3. A nurse is caring for a post-op patient. The doctor has ordered SCDs (sequential compression devices) to be applied to both lower extremities while on bedrest. Which of the following statements by the patient indicates the patient understands why SCDs are used?
      A)
      "This device will keep my joints in good shape."
      B)
      "This device will keep me from getting sores on my skin."
      C)
      "The SCDs will keep my legs from getting weak."
      D)
      "The SCDs will help prevent blood clots in my legs."
    4. Which of the following statements is true regarding the nature of pain?
      A)
      Pain tolerance is the minimum intensity of a stimulus that is perceived as painful.
      B)
      Culture and past experiences can affect the way a patient perceives pain.
      C)
      Pain is an objective finding.
      D)
      Pain always manifests physical signs and symptoms.
    Page 5 of 11

    Exam Review

    1. The nurse is working with a group of patients. Which patients are at risk for a skin breakdown? Select all that apply.
      A)
      The patient who has paralysis and is unable to move in bed.
      B)
      The incontinent patient who is diapered.
      C)
      The patient who is being discharged following an appendectomy.
      D)
      The patient who experienced numbness in the right arm that has resolved after several hours.
      E)
      The patient who has experienced vomiting and diarrhea for several days with a loss of 12 lb (5.4 kg) in weight.
    2. A home health nurse is coordinating care for a post-stroke patient who has difficulty swallowing and requires a modified diet. Which healthcare team member should the nurse consult first?
      A)
      Nutritionist
      B)
      Social worker
      C)
      Occupational therapist
      D)
      Speech therapist
    3. In planning to meet the nutritional needs of a critically ill patient in the intensive care unit, which factor will increase the patient's basal metabolic rate?
      A)
      Long periods of sleep
      B)
      Prolonged fasting
      C)
      Infection
      D)
      Advanced age
    4. Two people call in sick on the medical-surgical unit and no additional help is available. The team consists of a registered nurse (RN), a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP). Which of these activities should the nurse assign to the UAP?
      A)
      Assist with plans for any patients being discharged.
      B)
      Assess a patient after an acute myocardial infarction.
      C)
      Assist the patients on the unit who are able to ambulate.
      D)
      Dressing changes for those with non-complex wounds.
    Page 6 of 11