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    Exam Review

    1. 11-year-old female with cystic fibrosis was admitted with failure to thrive after losing 3 kilograms (6.6 pounds) over the past two weeks. This started following a hospitalization because of pneumonia, and the client could not regain the weight. The client's parents agreed to a short hospitalization to collaborate with a nutritionist, intravenous (IV) fluids, and other treatment interventions. On exam, the client is alert and completely oriented. The client has a sunken eye appearance, very dry and flaky skin. Brittle hair and nails were noted. Very thin appearance. No cardiac murmurs were noted, and some rhonchi in both lung fields. Productive cough noted with clear sputum. Bowel sounds were hyperactive in all four quadrants. The client reported no pain.

      The nurse reviews the physician's history and physical and plans care for the client

      ➢ For each potential intervention, click to specify if the intervention is indicated or contraindicated

      • A. Weigh the client daily
      • B. Perform chest physiotherapy following meals
      • C. Inquire about the client's dietary preferences
      • D. Administer prescribed pancrelipase after meals
      • E. Obtain a prescription for a multivitamin
      • F. Encourage snacks that are low in sodium
      • G. Plan to collaborate with a registered dietician

    2. The nurse is providing discharge instructions to a client who underwent left eye cataract surgery with a lens implant. Which statement by the client would indicate a correct understanding of the teaching?

      A)
      "I should avoid getting water in the eye for 3 to 7 days after surgery."
      B)
      "It is okay for me to resume normal chores such as vacuuming."
      C)
      "It is okay for me to have green or yellow, thick drainage from the eye."
      D)
      "I may take aspirin for any pain I may experience."

    3. The nurse is teaching 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)
      Baths with baking soda may help with the itching.
      E)
      Do not use any aspirin or ibuprofen during the illness.

    4. The nurse has provided medication instructions to a client who has been prescribed venlafaxine.

      ➢ Which of the following statements, if made by the client, would indicate a correct understanding of the teaching?

      Select all that apply.

      (SATA)
      A)
      “I may not notice an improvement in my mood right away.”
      B)
      “This medication may lower my blood pressure.”
      C)
      “If I have thoughts of harming myself, I should call 911.”
      D)
      “I will need to have weekly laboratory tests.”
      E)
      “I may continue taking St. John’s Wort.”
    Page 1 of 38

    Exam Review

    1. The nurse works on a medical-surgical unit and is responsible for assessing the client's vital signs. Which of the following clients can have their temperature measured orally?

      Select all that apply.

      (SATA)
      A)
      A 61-year-old woman who had oral surgery
      B)
      A 44-year old man with chest pain on oxygen via nasal canula
      C)
      An 83-year-old woman with diarrhea
      D)
      A 29-year-old client with an earache
      E)
      A 6-year-old client with a sore throat and difficulty swallowing

    2. Which of the following medications would be appropriate for the treatment of an allergic reaction to a blood transfusion?

      Select all that apply.

      (SATA)
      A)
      Epinephrine
      B)
      Acetaminophen
      C)
      Diphenhydramine
      D)
      Hydrocortisone
      E)
      Pantoprazole

    3. The nurse is preparing to obtain capillary blood glucose (CBG) for a client with diabetes mellitus. The nurse should take which action? Select all that apply.

      (SATA)
      A)
      Apply gloves for this procedure
      B)
      Have the client wash their hands with soap and water prior to blood collection
      C)
      Collect the second blood drop on the test strip
      D)
      Prick the central part of the finger for the sample
      E)
      Clean and disinfect the glucometer in between uses

    4. The nurse is caring for assigned clients in the mental health unit. The nurse should initially follow up on the client who

      A)
      is admitted for psychosis and is pacing in the hallway, mumbling to themselves.
      B)
      is being treated for obsessive compulsive disorder and has increased the number of times they wash their hands.
      C)
      has a substance use disorder and refuses to attend group therapy for the second time.
      D)
      is diagnosed with borderline personality disorder and is insisting on seeing the charge nurse for an allegation of abuse two days ago.
    Page 2 of 38

    Exam Review

    1. 1155: 26-year-old female presents with reports of dyspareunia, heavy menstrual bleeding, and pelvic pressure that intensifies during her menstrual cycle. The client states that the symptoms started four months ago and have intensified to the point where she refuses to have intercourse because of the pain. She has no children and reports fertility problems despite seeing two specialists. She reports that she has been treated for two urinary tract infections, but it still is occasionally painful when she urinates, especially during menstruation. She denies any vaginal odor or discharge other than heavy menstrual bleeding. She denies having any sores or lesions around her labia. She reports pelvic pain, described as a pressure rated as 4 on a scale of 0 (no pain) to 10 (severe pain) that is intensified during menstruation and sexual intercourse. She takes a daily multivitamin and denies any drug or alcohol use. She has no reported medical problems.

      T 97.5° F (36.4° C), P 81, RR 18, BP 138/84, pulse oximetry reading 96% on room air

      Clinical illustration

      ➢ Complete the sentence below from the list of options

      The client is at highest risk of developing [cervical cancer. / herpes simples virus (HSV). / endometriosis. / pelvic inflammatory disease. / bacterial vaginosis (BV).]

    2. 1450 -

      • Client was admitted directly from the primary healthcare physician's office for a severe exacerbation of systemic lupus erythematosus (SLE).
      • The client was being treated outpatient with corticosteroids but was not responding.
      • Reported intermittent chest pain at the physician's office and became pale and diaphoretic.
      • The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
      • The client was directly admitted to the intensive care unit for observation and medical management.
      • Cardiac consultation has been placed, and laboratory work is pending.
      • The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension

      1629 – Client's spouse alerted RN to the client reporting chest pain. On assessment, the client had a Glasgow coma scale of 15 and was pale on assessment. A butterfly-shaped rash across the cheeks and bridge of the nose. Clear lung fields bilaterally, muffled heart sounds. Radial peripheral pulses 2+. Client stated, "my chest hurts." Cardiac monitor showed sinus tachycardia with a rate of 119. + Jugular venous distention at 90 degrees. T 100° F (37.8° C) RR 25, P 119, BP 105/89. Pulse oximetry 95% on room air. An immediate 12-lead electrocardiogram (ECG) was obtained and showed sinus tachycardia with no ST-segment changes.

      1450 -

      • Admit to intensive care unit (ICU)
      • Continuous cardiac monitoring
      • Consultation with cardiology
      • Chest radiograph (x-ray)
      • Establish peripheral vascular access device

      Chest radiograph (x-ray)

      1635: Pericardial effusion with cardiomegaly. Enlarged cardiac silhouette. No lung abnormalities.

      1710 - Emergent bedside pericardiocentesis was performed because of the client's deteriorating hemodynamic status. 100 mL of pericardial fluid was aspirated. Post-procedure vital signs stabilized.

      ➢ Which of the following assessment findings require immediate follow-up? Select all that apply. 

      (SATA)
      A)
      lung sounds
      B)
      cardiac sounds
      C)
      temperature
      D)
      blood pressure
      E)
      butterfly-shaped rash on face
      F)
      pulse oximetry
      G)
      pulse

    3. 1450 -

      • Client was admitted directly from the primary healthcare physician's office for a severe exacerbation of systemic lupus erythematosus (SLE).
      • The client was being treated outpatient with corticosteroids but was not responding.
      • Reported intermittent chest pain at the physician's office and became pale and diaphoretic.
      • The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
      • The client was directly admitted to the intensive care unit for observation and medical management.
      • Cardiac consultation has been placed, and laboratory work is pending.
      • The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension

      1629 – Client's spouse alerted RN to the client reporting chest pain. On assessment, the client had a Glasgow coma scale of 15 and was pale on assessment. A butterfly-shaped rash across the cheeks and bridge of the nose. Clear lung fields bilaterally, muffled heart sounds. Radial peripheral pulses 2+. Client stated, "my chest hurts." Cardiac monitor showed sinus tachycardia with a rate of 119. + Jugular venous distention at 90 degrees. T 100° F (37.8° C) RR 25, P 119, BP 105/89. Pulse oximetry 95% on room air. An immediate 12-lead electrocardiogram (ECG) was obtained and showed sinus tachycardia with no ST-segment changes.

      1450 -

      • Admit to intensive care unit (ICU)
      • Continuous cardiac monitoring
      • Consultation with cardiology
      • Chest radiograph (x-ray)
      • Establish peripheral vascular access device

      Chest radiograph (x-ray)

      1635: Pericardial effusion with cardiomegaly. Enlarged cardiac silhouette. No lung abnormalities.

      1710 - Emergent bedside pericardiocentesis was performed because of the client's deteriorating hemodynamic status. 100 mL of pericardial fluid was aspirated. Post-procedure vital signs stabilized.

      ➢ Which of the following issues is the client at risk of developing? Select all that apply.

      A)
      cardiac tamponade
      B)
      cardiogenic shock
      C)
      stroke
      D)
      pneumothorax
      E)
      acute coronary syndrome

    4. 1450 -

      • Client was admitted directly from the primary healthcare physician's office for a severe exacerbation of systemic lupus erythematosus (SLE).
      • The client was being treated outpatient with corticosteroids but was not responding.
      • Reported intermittent chest pain at the physician's office and became pale and diaphoretic.
      • The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
      • The client was directly admitted to the intensive care unit for observation and medical management.
      • Cardiac consultation has been placed, and laboratory work is pending.
      • The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension

      1629 – Client's spouse alerted RN to the client reporting chest pain. On assessment, the client had a Glasgow coma scale of 15 and was pale on assessment. A butterfly-shaped rash across the cheeks and bridge of the nose. Clear lung fields bilaterally, muffled heart sounds. Radial peripheral pulses 2+. Client stated, "my chest hurts." Cardiac monitor showed sinus tachycardia with a rate of 119. + Jugular venous distention at 90 degrees. T 100° F (37.8° C) RR 25, P 119, BP 105/89. Pulse oximetry 95% on room air. An immediate 12-lead electrocardiogram (ECG) was obtained and showed sinus tachycardia with no ST-segment changes.

      1450 -

      • Admit to intensive care unit (ICU)
      • Continuous cardiac monitoring
      • Consultation with cardiology
      • Chest radiograph (x-ray)
      • Establish peripheral vascular access device

      Chest radiograph (x-ray)

      1635: Pericardial effusion with cardiomegaly. Enlarged cardiac silhouette. No lung abnormalities.

      1710 - Emergent bedside pericardiocentesis was performed because of the client's deteriorating hemodynamic status. 100 mL of pericardial fluid was aspirated. Post-procedure vital signs stabilized.

      The nurse reviews the results from the chest radiograph (x-ray)

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

      The client is ****most likely**** experiencing [acute coronary syndrome. / pneumothorax. / cardiac tamponade.]

    Page 3 of 38

    Exam Review

    1. 1450 -

      • Client was admitted directly from the primary healthcare physician's office for a severe exacerbation of systemic lupus erythematosus (SLE).
      • The client was being treated outpatient with corticosteroids but was not responding.
      • Reported intermittent chest pain at the physician's office and became pale and diaphoretic.
      • The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
      • The client was directly admitted to the intensive care unit for observation and medical management.
      • Cardiac consultation has been placed, and laboratory work is pending.
      • The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension

      1629 – Client's spouse alerted RN to the client reporting chest pain. On assessment, the client had a Glasgow coma scale of 15 and was pale on assessment. A butterfly-shaped rash across the cheeks and bridge of the nose. Clear lung fields bilaterally, muffled heart sounds. Radial peripheral pulses 2+. Client stated, "my chest hurts." Cardiac monitor showed sinus tachycardia with a rate of 119. + Jugular venous distention at 90 degrees. T 100° F (37.8° C) RR 25, P 119, BP 105/89. Pulse oximetry 95% on room air. An immediate 12-lead electrocardiogram (ECG) was obtained and showed sinus tachycardia with no ST-segment changes.

      1450 -

      • Admit to intensive care unit (ICU)
      • Continuous cardiac monitoring
      • Consultation with cardiology
      • Chest radiograph (x-ray)
      • Establish peripheral vascular access device

      Chest radiograph (x-ray)

      1635: Pericardial effusion with cardiomegaly. Enlarged cardiac silhouette. No lung abnormalities.

      1710 - Emergent bedside pericardiocentesis was performed because of the client's deteriorating hemodynamic status. 100 mL of pericardial fluid was aspirated. Post-procedure vital signs stabilized.

      The nurse notifies the physician of the client's condition change, and the physician arrives at the client's bedside and determines that the client is experiencing cardiac tamponade

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

      • A. Prepare the client for an immediate thoracentesis
      • B. Obtain a prescription for an isotonic fluid bolus
      • C. Perform frequent vital sign collection
      • D. Obtain a prescription for intravenous furosemide

    2. 1450 -

      • Client was admitted directly from the primary healthcare physician's office for a severe exacerbation of systemic lupus erythematosus (SLE).
      • The client was being treated outpatient with corticosteroids but was not responding.
      • Reported intermittent chest pain at the physician's office and became pale and diaphoretic.
      • The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
      • The client was directly admitted to the intensive care unit for observation and medical management.
      • Cardiac consultation has been placed, and laboratory work is pending.
      • The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension

      1629 – Client's spouse alerted RN to the client reporting chest pain. On assessment, the client had a Glasgow coma scale of 15 and was pale on assessment. A butterfly-shaped rash across the cheeks and bridge of the nose. Clear lung fields bilaterally, muffled heart sounds. Radial peripheral pulses 2+. Client stated, "my chest hurts." Cardiac monitor showed sinus tachycardia with a rate of 119. + Jugular venous distention at 90 degrees. T 100° F (37.8° C) RR 25, P 119, BP 105/89. Pulse oximetry 95% on room air. An immediate 12-lead electrocardiogram (ECG) was obtained and showed sinus tachycardia with no ST-segment changes.

      1450 -

      • Admit to intensive care unit (ICU)
      • Continuous cardiac monitoring
      • Consultation with cardiology
      • Chest radiograph (x-ray)
      • Establish peripheral vascular access device

      Chest radiograph (x-ray)

      1635: Pericardial effusion with cardiomegaly. Enlarged cardiac silhouette. No lung abnormalities.

      1710 - Emergent bedside pericardiocentesis was performed because of the client's deteriorating hemodynamic status. 100 mL of pericardial fluid was aspirated. Post-procedure vital signs stabilized.

      The physician orders an emergent pericardiocentesis to be performed at the bedside

      ➢ Complete the sentences below from the list of the options

      The nurse prepares the client for an emergent pericardiocentesis and it is essential to have [a bottle of sterile water / a defibrillator / positive pressure ventilation] at the bedside. During the procedure, it is ****priority**** for the nurse to monitor the client's [urinary output. / cardiac rhythm. / Glasgow coma scale.]

    3. 1450 -

      • Client was admitted directly from the primary healthcare physician's office for a severe exacerbation of systemic lupus erythematosus (SLE).
      • The client was being treated outpatient with corticosteroids but was not responding.
      • Reported intermittent chest pain at the physician's office and became pale and diaphoretic.
      • The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
      • The client was directly admitted to the intensive care unit for observation and medical management.
      • Cardiac consultation has been placed, and laboratory work is pending.
      • The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension

      1629 – Client's spouse alerted RN to the client reporting chest pain. On assessment, the client had a Glasgow coma scale of 15 and was pale on assessment. A butterfly-shaped rash across the cheeks and bridge of the nose. Clear lung fields bilaterally, muffled heart sounds. Radial peripheral pulses 2+. Client stated, "my chest hurts." Cardiac monitor showed sinus tachycardia with a rate of 119. + Jugular venous distention at 90 degrees. T 100° F (37.8° C) RR 25, P 119, BP 105/89. Pulse oximetry 95% on room air. An immediate 12-lead electrocardiogram (ECG) was obtained and showed sinus tachycardia with no ST-segment changes.

      1450 -

      • Admit to intensive care unit (ICU)
      • Continuous cardiac monitoring
      • Consultation with cardiology
      • Chest radiograph (x-ray)
      • Establish peripheral vascular access device

      Chest radiograph (x-ray)

      1635: Pericardial effusion with cardiomegaly. Enlarged cardiac silhouette. No lung abnormalities.

      1710 - Emergent bedside pericardiocentesis was performed because of the client's deteriorating hemodynamic status. 100 mL of pericardial fluid was aspirated. Post-procedure vital signs stabilized.

      The nurse reviews the physician's progress note following the procedure

      Two days later, the client received discharge orders home, and the nurse provided discharge teaching

      ➢ The nurse teaches the client self-care practices for systemic lupus erythematosus (SLE). Which two (2) client statements indicate effective understanding?

      A)
      “I should limit my exposure to direct sunlight to 45 continuous minutes each day.”
      B)
      "I should wear long sleeves and a large-brimmed hat when outdoors."
      C)
      “I should wash my skin with an antibacterial soap.”
      D)
      "Cosmetics must be selected carefully and should include moisturizers and sun protectors."
      E)
      "I should refrain from receiving any vaccine."

    4. A client with a history of falls is admitted to the medical-surgical unit. The nurse should plan to implement which intervention to reduce this client's risk of falling?

      A)
      Encouraging the client to ambulate independently to improve muscle strength.
      B)
      Verify that the bed alarm is enabled during client rounding.
      C)
      Implementing a fall risk assessment every two days
      D)
      Implementing a restrictive mobility policy to minimize the potential of falls.
    Page 4 of 38

    Exam Review

    1. The nurse is caring for a client who has been diagnosed with septic shock. The nurse understands that which of the following is considered a key characteristic of septic shock?

      A)
      Low respiratory rate
      B)
      Decreased serum lactate levels
      C)
      Elevated serum bicarbonate levels
      D)
      Hypotension despite adequate fluid replacement

    2. The nurse is administering a continuous infusion of magnesium sulfate to a client with preeclampsia. Which assessment data is necessary to monitor during the infusion?

      A)
      capillary blood glucose
      B)
      urine specific gravity
      C)
      range of motion of lower extremities
      D)
      heart rate and rhythm

    3. The nurse is interviewing a family and observes tension between the two parents, and the child reports that the mother often involves her in deciding who is right. This observation is an example of

      A)
      triangulation.
      B)
      coalition.
      C)
      fusion.
      D)
      differentiation.

    4. The nurse is teaching a client who is receiving newly prescribed hydroxychloroquine.

      ➢ Which of the following information should the nurse include?

      A)
      “You will need regular eye exams while taking this medication.”
      B)
      “This medication helps increase bone strength over time.”
      C)
      “This medication may cause your white blood cell count to rise.”
      D)
      "This medication may raise your blood glucose."
    Page 5 of 38

    Exam Review

    1. 1400: Client reports swelling, erythema, and painful lesion to the left upper extremity. The client reports that he noticed a pimple-like lesion three days ago that grew in size and became painful over the course of three days. The client has a medical history of diabetes mellitus (type one) and has noticed higher-than-normal blood glucose levels. The client reports that pain has increased to a level where he cannot go to the gym daily. On assessment, the client has a large, reddened pustule in the left upper extremity. Pain rated 7/10 on the Numerical Rating Scale. Vital signs: T 98.7° F (37.1° C) P 88 RR 16 BP 138/84 Pulse oximetry reading 99% on room air.

      1519: Bedside I&D performed by physician. Applied 4x4 gauze sponge to the wound and wrapped with rolled sterile gauze. Culture and sensitivity were obtained and sent to the lab.

      1610: Discharged client home. Discharge teaching provided. Vital signs: T 98.7° F (37.1° C) P 82 RR 17 BP 133/81 Pulse oximetry reading 98% on room air.

      1400:

      • obtain supplies for incision and drainage (I&D)
      • culture and sensitivity of the wound drainage

      1509:

      • discharge client home
      • follow-up with primary healthcare provider (PHCP) in three days
      • discharge prescription: trimethoprim/sulfamethoxazole 160mg/800mg one tablet PO every twelve hours for 7 days
      • discharge client with wound care supplies

      1514: Bedside I&D was performed on a left upper extremity abscess. Area was prepped and cleaned with povidone iodine. 1% lidocaine infiltrated for anesthesia. A large amount of purulent, foul-smelling drainage was removed from the abscess. Minimal blood loss. Client tolerated the procedure with no reports of discomfort. Area was dressed by nursing. Strong suspicion of MRSA abscess.

      The nurse provides the client with discharge teaching on wound care and the prescribed antibiotic.

      ➢ For each of the statements made by the client, click to specify whether the statement indicates an understanding or no understanding of the discharge teaching provided.

      Note: Each row must have 1 response option selected.

      • A. Increase fluid intake
      • B. Wear broad-spectrum sunscreen
      • C. Infection raises glucose

    2. The nurse is caring for a client with right-sided weakness.

      ➢ When transferring the client from the bed to a wheelchair, which action should the nurse perform?

      A)
      Place the wheelchair as close to the bed as possible on the client's unaffected side
      B)
      Place the wheelchair as close to the bed as possible on the client's affected side
      C)
      Remove any nonskid slippers from the client's feet
      D)
      Gently pull on the client's arm to assist them to the side of the bed

    3. The nurse is performing an assessment on a client experiencing psychosis. The client states, "I went to the store this morning, and many people wore different shoes. I've always wanted to travel to Paris, but I don't like flying. Maybe I'll go to the beach instead; it's so relaxing."

      ➢ It would be appropriate for the nurse to categorize these statements as

      A)
      tangential speech.
      B)
      grandiose delusions
      C)
      circumstantial speech.
      D)
      persecutory delusions.

    4. 0920: Client presents for a follow-up visit. Client reports increased difficulty with activities of daily living because of dyspnea. Reports pain and swelling in both lower extremities that increases with movement. "Washing my hair now takes me an hour instead of fifteen minutes." Transverse surgical incision was pink, approximated, and crusted—9 inches in length. Two Jackson-Pratt drains contained a total of 15 mL of serumlike drainage. Incisional pain reported at a '4' on the Numerical Rating Scale. Endorses increased incisional pain while coughing. The client reports full adherence to postoperative enoxaparin self-injections. She reports ejecting the air bubble prior to injection. Reports relief with prescribed oxycodone-acetaminophen but experiences generalized itching and drowsiness after.

      • gastric bypass surgery performed two years ago
      • dyslipidemia
      • diabetes mellitus (type two)

      T 99.0°F (37.2°C); HR 90 beats/min; RR 18 breaths/min; BP 119/67 mm Hg; Pulse oximetry 96% on room air.

      ➢ Which of the following assessment findings require immediate follow-up? Select all that apply.

      A)
      wound assessment findings
      B)
      tolerance with activities of daily living
      C)
      incision pain level and characteristics
      D)
      pulse, respirations, and blood pressure
      E)
      temperature and pulse oximetry reading
      F)
      pain in lower extremities
      G)
      surgical drain assessment findings
      H)
      enoxaparin self-injections
      I)
      response to prescribed pain medication
    Page 6 of 38