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    Exam Review

    1. The nurse has been made aware of the following client situations. The nurse should initially follow up with the client who

      A)
      had an adrenalectomy 24 hours ago and has become restless with the most recent blood pressure (BP) of 98/60 mm Hg.
      B)
      has a continuous infusion of heparin for the treatment of a pulmonary embolism (PE) and has an activated partial thromboplastin time (aPTT) of 70 seconds (normal 30-40 seconds).
      C)
      is receiving mechanical ventilation to treat hospital-acquired pneumonia (HAP) and was last suctioned via the endotracheal (ET) tube two hours ago.
      D)
      has a newly placed chest tube for hemothorax and has had 45 mL of bright red drainage in the past hour.

    2. The nurse is discussing risk factors for breast cancer at a local community college. Which of the following should the nurse include in the presentation? Select all that apply.

      (SATA)
      A)
      Nulliparity
      B)
      Multiparity
      C)
      Early menarche
      D)
      Overweight or obesity
      E)
      Multiple sexual partners
      F)
      Human papillomavirus

    3. The nurse is assessing a client who was just diagnosed with acute pyelonephritis. Which of the following findings should the nurse expect to observe? Select all that apply.

      (SATA)
      A)
      Costovertebral angle tenderness
      B)
      Jugular venous distention
      C)
      Fever and chills
      D)
      Urinary retention
      E)
      Dysuria

    4. The nurse is teaching a group of students about drug toxicity. The nurse is correct in stating which of the following?

      Select all that apply.

      (SATA)
      A)
      “Naloxone is the treatment for opioid toxicity.”
      B)
      “Magnesium is the treatment for lead toxicity.”
      C)
      “N-acetylcysteine is the treatment for naproxen toxicity.”
      D)
      “Calcium gluconate is the treatment for magnesium toxicity.”
      E)
      “Flumazenil is the treatment for benzodiazepine toxicity.”
    Page 1 of 38

    Exam Review

    1. The nurse is caring for assigned clients. Which of the following clients would be appropriate for the nurse to refer for an interdisciplinary conference? A client with

      Select all that apply.

      (SATA)
      A)
      pulmonary tuberculosis with multiple prescriptions.
      B)
      ischemic stroke who has left-sided hemiplegia.
      C)
      hyperthyroidism and is scheduled for a thyroidectomy.
      D)
      stage one Alzheimer’s disease who lives with family.
      E)
      fractured tibia and fibula and is homeless.
      F)
      end-stage-renal disease who refuses dialysis.

    2. The nurse works in a long-term psychiatric rehabilitation center and is assigned to a patient with debilitating agoraphobia. The patient is going through desensitization therapy. Which of the following interventions is an appropriate part of this treatment?

      Select all that apply.

      (SATA)
      A)
      Speak frequently of what causes the fear to start for him.
      B)
      Take a short walk in the hallway outside of his room.
      C)
      Build rapport with the client
      D)
      Encourage him to face his fear outside where he is least comfortable.
      E)
      Teach anxiety management techniques

    3. The nurse is performing a continuing education program about fluid and electrolytes.

      ➢ It would be appropriate for the nurse to reinforce that which intravenous (IV) solution is hypertonic? Select all that apply.

      (SATA)
      A)
      3% saline
      B)
      Dextrose 10% in water (D10W)
      C)
      5% Dextrose with 0.45% Sodium Chloride
      D)
      Lactated Ringers (LR)
      E)
      0.45% Sodium Chloride (0.45% NaCl)

    4. The nurse is caring for a client who is receiving the prescribed hydromorphone. Which of the following side effects should the nurse look for in the client?

      Select all that apply.

      (SATA)
      A)
      Urinary incontinence
      B)
      Pupil dilation
      C)
      Diarrhea
      D)
      Altered level of consciousness (LOC)
      E)
      Constipation
    Page 2 of 38

    Exam Review

    1. The nurse is caring for a child immediately following a nephrectomy in the postanesthesia care unit (PACU). Which assessment should the nurse initially perform?

      A)
      pain level
      B)
      peripheral vascular access device
      C)
      surgical incision
      D)
      vital signs

    2. The nurse has attended a continuing education conference about infection control precautions. It would indicate a correct understanding of the education if the nurse is observed

      A)
      using dedicated client-care equipment for a client with Clostridium difficile.
      B)
      wearing a particulate respirator mask (N95) while caring for a client with epiglottitis, due to Haemophilus influenzae type b.
      C)
      placing a surgical mask on a client being transported with radiology who has infectious mononucleosis.
      D)
      keeping the door closed for a client with cryptococcosis meningitis.

    3. The nurse is caring for a client with diabetes mellitus (type one) with diabetic ketoacidosis (DKA).

      ➢ Which laboratory result is critical for the nurse to monitor closely during the client's treatment?

      A)
      Blood urea nitrogen (BUN)
      B)
      Serum creatinine
      C)
      Serum potassium
      D)
      Serum magnesium

    4. The nurse is caring for a client with vasodilatory shock who is receiving a vasopressin infusion. Which nursing intervention is most important for this client?

      A)
      Encouraging fluid intake of at least 2 liters per day
      B)
      Checking blood pressure every 15 minutes
      C)
      Monitoring urine output every 2 hours
      D)
      Assessing for signs of myocardial ischemia every 4 hours
    Page 3 of 38

    Exam Review

    1. 1242: The client presents concerns for anxiety and some depression following the announcement of the divorce of her parents three weeks ago. She stated that she and her siblings are experiencing a "whirlwind" of emotions ranging from sadness, anger, and anxiety. The client initially disbelieved about her parents' divorce. However, she realized the divorce was happening because her father was packing his belongings and moving out of their home. She noticed that in the past few weeks, her grades have dropped. She has final exams coming, stating, "I just want to put this incident aside until after my exams, when I can give it my full concentration."

      ➢ Complete the following sentence by choosing from the list of options.

      The nurse recognizes that the client is demonstrating [sublimation / reaction formation / suppression / regression] to deal with her feelings related to her parent's divorce.

    2. The nurse is preparing to administer enoxaparin.

      ➢ Which of the following laboratory test results should the nurse monitor while the client is receiving enoxaparin?

      A)
      platelet count
      B)
      activated partial thromboplastin time (aPTT)
      C)
      international normalized ratio (INR)
      D)
      white blood cell (WBC) count

    3. 2122: Client arrives via emergency medical services (EMS) for a thermal burn sustained while igniting fireworks. On assessment, the client sustained full-thickness burns to the face, anterior torso, bilateral arms, and bilateral legs. Vital signs: T 99.7° F (37.6° C), P 106, RR 24, BP 188/90, pulse oximetry reading 95% on room air.

      The nurse performs an assessment of the client's burn injuries.

      ➢ Complete the sentence below from the list of options

      Based on the client’s injuries, the client has sustained a [50% / 75% / 46.5% / 76.5%] total body surface area burn.

    4. 1923: Assessment completed. Peripheral vascular access device (PAD) was assessed. Erythema and swelling were noted at the insertion site. The client reported "severe" pain, and tenderness was endorsed when it was palpated. The infusion was stopped.

      • dopamine 5 mcg/kg/min via continuous infusion

      The nurse reviews the assessment and is preparing to take action.

      ➢ For each potential action, click to specify whether the potential action is indicated or not indicated for the client.

      • A. Remove the peripheral vascular access device
      • B. Obtain an order for phentolamine
      • C. Notify the physician
      • D. Flush the intravenous vascular access device with 5 mL of 0.9% saline (sodium chloride)
      • E. Disconnect administration set
    Page 4 of 38

    Exam Review

    1. The nurse in the emergency department (ED) is caring for an unconscious client who sustained a head injury following a motor vehicle crash. The health care provider (HCP) has ordered an emergency surgery.

      ➢ Which action should the nurse take regarding informed consent?

      A)
      obtain a court order for the surgical procedure in place of an informed consent
      B)
      search the client's belongings for any identification
      C)
      transport the client to the operating room for surgery immediately
      D)
      call the police to report the incident, identify the client, and locate the family

    2. A client with sickle cell anemia is asking the nurse about potential activities that will not aggravate the condition. It would be appropriate for the nurse to recommend that the client

      A)
      hike up a mountain range to camp overnight.
      B)
      go snow skiing for the weekend.
      C)
      ride a snowmobile during the day.
      D)
      take a drive to have a picnic on the beach.

    3. The nurse in the behavioral health clinic is interviewing a client with depression. The nurse tells the client, 'Sometimes having a mental illness can feel very discouraging. I wonder how you are feeling?' By making this statement, the nurse is demonstrating

      A)
      empathy.
      B)
      reassurance.
      C)
      normalizing.
      D)
      sympathy.

    4. A G1P0 client currently in the 28th week of gestation whose blood type is A negative was advised to receive a Rho(D) immune globulin intramuscular injection today. Which statement by the client indicates the need for further teaching about this therapy by the nurse?

      A)
      "This shot is meant to prevent my baby from developing antibodies against my blood, right?"
      B)
      "I understand that if we find out my baby is Rh-positive, I'll need another one of these injections after delivery."
      C)
      "This shot should help to protect future pregnancies if this baby comes out Rh positive, although each future pregnancy will require a repeat dose."
      D)
      "This shot will prevent me from making Rh antibodies."
    Page 5 of 38

    Exam Review

    1. The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients.

      ➢ Which of the following tasks would be appropriate for the nurse to assign to UAP? Select all that apply.

      A)
      Transport a client with an ankle fracture to radiology.
      B)
      Calculate and record a client's oral intake for the shift.
      C)
      Ambulate a client who is eight hours post-laparoscopic surgery.
      D)
      Assist a client with multiple sclerosis in performing oral care.
      E)
      Obtain a urine culture and sensitivity sample from an indwelling urethral catheter.

    2. The nurse is planning care for a client who is receiving mechanical ventilation via an endotracheal tube (ETT).

      ➢ Which acid-base imbalance would suggest that the client may need to have their ETT suctioned?

      A)
      Respiratory acidosis
      B)
      Metabolic alkalosis
      C)
      Respiratory alkalosis
      D)
      Metabolic acidosis

    3. 2300: Client is a primigravida at 33 weeks gestation, who awoke to moderate bright red vaginal bleeding. She reports noticing light spotting earlier in the day, which she dismissed as benign. She denies abdominal pain, cramping, or contractions. Her pregnancy has been uncomplicated until recently. She reports increased fetal movement over the last 48 hours. One week ago, she presented to the ED with fever, fatigue, and body aches, and was diagnosed with influenza A. She was treated supportively and discharged home with hydration instructions. Over the past 24 hours, she has experienced nasal congestion and fatigue.

      Four days ago, a transabdominal ultrasound showed:

      • Fetus in cephalic position
      • Normal amniotic fluid volume

      Exam findings

      • Abdomen: Soft, non-tender
      • No uterine contractions noted on palpation
      • Moderate amount of dried bright red blood was seen on the undergarments
      • 1+ pedal edema
      • Peripheral pulses 2+

      2342: Fetal Heart Rate (FHR): 144 bpm, moderate variability, no decelerations

      Temperature: 99.5°F (37.5°C)

      HR 88 bpm

      BP 137/78 mmHg

      RR 18/min

      Pulse oximetry 98% on room air

      ➢ Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client’s progress.

      Actions to Take: Request a prescription for indomethacin | Prepare the client for a transvaginal ultrasound | Place the client in the lithotomy position for a manual cervical exam | Establish a peripheral vascular access device | Place the client in a room with monitored negative airflow

      Potential Conditions: Placental abruption | Preeclampsia | Placenta previa | Influenza recurrence

      Parameters to Monitor: Fetal heart rate pattern | Pedal edema | Amount and color of vaginal bleeding | Temperature | Nasal congestion and fatigue level

      Actions to Take: Request a prescription for indomethacin | Prepare the client for a transvaginal ultrasound | Place the client in the lithotomy position for a manual cervical exam | Establish a peripheral vascular access device | Place the client in a room with monitored negative airflow

      Parameters to Monitor: Fetal heart rate pattern | Pedal edema | Amount and color of vaginal bleeding | Temperature | Nasal congestion and fatigue level

    4. The nurse is providing care to an 11-week pregnant client who is complaining about hemorrhoids. The nurse recognizes that hemorrhoids can occur due to pressure on the rectal veins from the growing fetus. Which of the following measures is not recommended for alleviating hemorrhoid pain in this client?

      A)
      Instruct the client to use mineral oil to soften her stools.
      B)
      Rest in a side-lying position daily.
      C)
      Increase the client’s fiber and water intake.
      D)
      Apply a cold compress to the area.
    Page 6 of 38