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    Exam Review

    1. The nurse is working with a new nurse who is caring for a client bitten by a venomous snake in the left hand. Which of the following interventions by the newly hired nurse requires follow-up?

      A)
      Applying a tourniquet proximal to the bite.
      B)
      Removing the client’s wristwatch and jewelry.
      C)
      Immobilizes the affected extremity.
      D)
      Obtaining a type and crossmatch for fresh frozen plasma (FFP).

    2. The nurse is reinforcing teaching to parents of a child diagnosed with varicella. Which of the following information should the nurse include? Select all that apply. 

      (SATA)
      A)
      Your child may return to school once the lesions have crusted.
      B)
      Your child should take the entire course of antibiotics.
      C)
      Acetaminophen may be used for fever.
      D)
      Warm baths with baking soda may help with the itching.
      E)
      Do not use any aspirin or ibuprofen during the illness.

    3. The nurse is developing a plan of care for a client diagnosed with Kawasaki disease. Which of the following should the nurse include in the client's plan of care?

      Select all that apply.

      (SATA)
      A)
      Initiate contact precautions
      B)
      Obtain a 12-lead electrocardiogram
      C)
      Offer soft foods and liquids
      D)
      Implement fluid restriction
      E)
      Administer aspirin, as prescribed

    4. The nurse is caring for a client experiencing pulmonary edema. The nurse should take which action? Select all that apply.

      (SATA)
      A)
      Administer prescribed furosemide
      B)
      Elevate the head-of-the-bed to 60 degrees
      C)
      Obtain a STAT chest computed tomography (CT) scan
      D)
      Notify the Rapid Response Team (RRT)
      E)
      Provide oxygen via nasal cannula
      F)
      Administer prescribed morphine
    Page 1 of 38

    Exam Review

    1. The nurse is caring for a client receiving intermittent bolus tube feeds. The nurse prepares to begin the next feed and aspirates 85 mL of residual from the nasogastric tube. Which of the following actions are appropriate?

      Select all that apply.

      (SATA)
      A)
      Document the color, odor, consistency, and amount of the residual.
      B)
      Hold the next feeding.
      C)
      Send the residual to the lab.
      D)
      Administer the residual back to the client.
      E)
      Administer the feeding, but subtract the quantity of the residual from the feed.

    2. The practical nurse is assisting in the monitoring of a client with a chest tube and notes each of the following findings. Which of the following are expected findings with the care of a chest tube?

      Select all that apply.

      (SATA)
      A)
      Drainage system at a level below the patient’s chest
      B)
      Vigorous bubbling in the water-seal chamber
      C)
      Stable water in the tube of the water-seal chamber during inhalation and exhalation.
      D)
      Occlusive dressing over the chest-tube
      E)
      Stable vital signs

    3. The nurse is caring for a client who has undergone a repair of an anorectal malformation. What interventions should the nurse anticipate?

      Select all that apply.

      (SATA)
      A)
      Loperamide administration
      B)
      Initiation of a high-calorie diet
      C)
      Docusate sodium administration
      D)
      Initiation of a high-fiber diet
      E)
      Monitor the client for signs of infection

    4. Which of the following interventions should the nurse anticipate for an infant with an omphalocele awaiting surgical repair?

      Select all that apply.

      (SATA)
      A)
      Cover the intestines with a sterile gauze soaked in saline
      B)
      Prone positioning
      C)
      Radiant warmer for thermoregulation
      D)
      Trophic feedings
      E)
      Assessing the infant's bowel function
    Page 2 of 38

    Exam Review

    1. The nurse is caring for an infant recently diagnosed with phenylketonuria (PKU). Which of the following complications should the nurse monitor for?

      Select all that apply.

      (SATA)
      A)
      Lethargy
      B)
      Irritability
      C)
      Nausea and vomiting
      D)
      Flaccid tone
      E)
      Seizures

    2. The licensed practical/vocational nurse (LPN/VN) is caring for a 14-month-old client receiving oral iron supplementation and observes a dark black stool in the diaper.

      ➢ The LPN/VN should take which action? Select all that apply.

      (SATA)
      A)
      Notify the primary healthcare provider (PHCP).
      B)
      Document the finding.
      C)
      Continue with the data collection.
      D)
      Administer the oral iron supplement as prescribed.
      E)
      Report possible gastrointestinal bleed to Registered Nurse (RN) supervisor

    3. The nurse is reinforcing education to a client with type 1 diabetes about exercise guidelines. Which of the following instructions are most appropriate for the nurse to give to the client?

      Select all that apply.

      A)
      “Be sure to eat a simple carbohydrate snack before you exercise.”
      B)
      “Do not administer insulin immediately before and after exercise.”
      C)
      “It is best to eat a more complex carbohydrate before you exercise so that you don’t bottom out.”
      D)
      “You may want to leave an energy drink with electrolytes in your gym locker in case you need it.”
      E)
      “It is smart to alert your gym that you have type 1 diabetes.”

    4. The nurse is caring for a client with diabetes mellitus. Which of the following laboratory data requires follow-up? Select all that apply.

      A)
      Hemoglobin A1C 8.5% [﹤ 5.7%]
      B)
      Creatinine 1.9 mg/dL [0.6-1.2 mg/dL]
      C)
      Total cholesterol 188 mg/dL [﹤ 200 mg/dL]
      D)
      BUN 25 mg/dL [10-20 mg/dL]
      E)
      Proteinuria
    Page 3 of 38

    Exam Review

    1. The nurse has attended a continuing education presentation about acid-base imbalances. It would indicate a correct understanding of the conference if the nurse identifies which of the following as a cause for metabolic acidosis? Select all that apply.

      A)
      Severe diarrhea
      B)
      Hyperventilation
      C)
      Starvation
      D)
      End-stage renal disease (ESRD)
      E)
      Nasogastric tube (NGT) suctioning

    2. The nurse is reinforcing teaching with the parents of a child diagnosed with impetigo. Which of the following statements, if made by the parent, would indicate effective understanding? Select all that apply.

      A)
      It is the most common bacterial skin infection between the ages of 2 and 5.
      B)
      The torso is the area most commonly affected by impetigo.
      C)
      The causative agent of impetigo is Haemophilus influenzae.
      D)
      Impetigo is usually not a systemic infection.
      E)
      "I should keep my child home from swim practice until the blisters heal."
      F)
      "I should not share my child's linens with anyone else in the house."

    3. The nurse is caring for a child with eczema. Which of the following findings should the nurse expect? Select all that apply

      A)
      Erythema
      B)
      Pruritus
      C)
      Papules
      D)
      Skin ulcers
      E)
      Scaly circular rash

    4. The nurse assesses each of the following on a 12-year-old female. Which of the following growth milestones are expected for female adolescents of this age?

      Select all that apply.

      A)
      Menarche
      B)
      Thelarche
      C)
      Deepening voice
      D)
      Development of facial hair
      E)
      Hirsutism
    Page 4 of 38

    Exam Review

    1. Which of the following findings indicate a risk for developing a decubitus ulcer in an 80-year-old client who recently had a hip replacement?

      Select all that apply.

      A)
      The patient takes her time to think about responses to questions.
      B)
      The patient’s age.
      C)
      The patient reports an inability to control urine.
      D)
      A scheduled hip arthroplasty.
      E)
      Lab findings of BUN 12 and creatinine 0.9.
      F)
      The patient reports increased pain in the right hip when repositioning in the bed or chair.

    2. The nurse has attended a staff education program about managing clients with peripheral arterial disease. Which of the following statements by the nurse would require follow-up?

      A)
      "The client should engage in a daily exercise regimen."
      B)
      "Smoking cessation is an essential treatment goal for clients who smoke."
      C)
      "Resting in a recliner with the legs dependent should be recommended."
      D)
      "Devices that elevate the legs above the heart should be provided at discharge."

    3. The nurse in the emergency department (ED) is triaging a child who was bitten by a dog and sustained a wound to the right forearm. Which potential nursing interventions are indicated? Select all that apply. 

      A)
      clean the wound with soap and water
      B)
      ask the child about the circumstances of the attack
      C)
      place the right arm in a dependent position
      D)
      obtain a prescription for oral antifungal medication
      E)
      notify public health services of the attack

    4. The licensed practical/vocational nurse (LPN/VN) is collecting data on a client with anaphylactic shock. Which of the following findings would support a diagnosis of anaphylactic shock?

      A)
      hypertension
      B)
      crackles (rales) in the lung fields
      C)
      cutaneous cyanosis
      D)
      pruritus
    Page 5 of 38

    Exam Review

    1. The licensed practical/vocational nurse (LPN/VN) is collecting data on a client with diabetes mellitus. It would suggest to the nurse that the client has developed severe hyperglycemia if the client

      A)
      has bounding peripheral pulses.
      B)
      has developed seizure activity.
      C)
      reports feeling anxious or nervous.
      D)
      has developed rapid, deep respirations.

    2. The nurse at a health fair is talking with a client who is in perimenopause. Which of the following client statements requires follow-up by the nurse? Select all that apply. 

      A)
      "I am using oil-based vaginal lubricants to lessen the discomfort during intercourse."
      B)
      "My doctor recommended I start taking Black cohosh to help with the loss of bone density"
      C)
      "I stopped exercising to reduce my hot flashes."
      D)
      "I recently started increasing my water intake to help prevent urinary tract infections."
      E)
      "Doing Kegel exercises will increase muscle tone around my vagina and urinary meatus."

    3. The nurse is caring for an infant who is experiencing a tetralogy of Fallot (tet) spell. Which of the following is the nurse's priority action?

      A)
      Administer propranolol
      B)
      Administer sodium bicarbonate
      C)
      Calm the infant
      D)
      Notify the healthcare provider

    4. The licensed practical/vocational nurse (LPN/VN) is caring for a 16-year-old client with cystic fibrosis. While obtaining vital signs, the client reports a productive cough and has a temperature of 101.2° F (38.4° C).

      ➢ The LPN/VN contacts the physician and should obtain a prescription for

      A)
      azithromycin.
      B)
      pancrealipase.
      C)
      multivitamin.
      D)
      albuterol.
    Page 6 of 38