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    Exam Review

    1. The nurse is caring for a hospitalized patient. Which behavior alerts the nurse to consider the temporary need for restraint?
      A)
      The patient does not sleep and continues to ask for items
      B)
      The patient continues to remove the nasogastric tube
      C)
      The patient refuses to call for help to go to the bathroom
      D)
      The patient gets confused regarding the time at night
    2. During the admission assessment, the nurse assesses the patient for fall risk. Which finding will alert the nurse to an increased risk for falls?
      A)
      The patient walks only 2 miles a day
      B)
      The patient is oriented
      C)
      The patient takes a hypnotic
      D)
      The patient recently became widowed
    3. An adult patient presents to the emergency department and is treated for hypothermia. What risk factor should the patient be assessed for?
      A)
      Homelessness
      B)
      High carbohydrate diet
      C)
      Tobacco use
      D)
      History of chronic respiratory disorder
    4. A nurse enters the hospital room of a patient who had a total knee replacement the day before and is sitting in a chair. The nurse is preparing to return the patient to bed. Which of the following pose potential safety risks? (Select all that apply.)
      (SATA)
      A)
      A current safety inspection sticker is on the IV fluid pump.
      B)
      A walker is positioned near the patient's bedside.
      C)
      The hospital bed is in the high position.
      D)
      There is no gait belt at the bedside.
      E)
      The overbed table with the patient's glasses is positioned against the wall opposite the end of the bed.
    Page 1 of 20

    Exam Review

    1. The patient has contracted a urinary tract infection (UTI) while in the hospital. Which action will most likely increase the risk of a patient contracting a UTI?
      A)
      Emptying the urinary drainage bag at least once a shift
      B)
      Irrigating the catheter infrequently
      C)
      Allowing the drainage bag port to touch the graduated receptacle
      D)
      Reusing the patient's graduated receptable to empty the drainage bag
    2. The nurse is caring for a patient who has just delivered a neonate. The nurse is checking the patient for excessive vaginal drainage. Which precaution will the nurse use?
      A)
      Protective environment
      B)
      Standard
      C)
      Contact
      D)
      Droplet
    3. The nurse is caring for a patient diagnosed with leukemia and is preparing to provide fluids through a vascular access (IV) device. Which nursing intervention is a priority in this procedure?
      A)
      Position the patient comfortably
      B)
      Review the procedure with the patient
      C)
      Gather available supplies
      D)
      Maintain surgical aseptic technique
    4. A patient presents with pneumonia. Which priority intervention should be included in the plan of care for this patient?
      A)
      Observe the patient for decreased activity tolerance
      B)
      Assume the patient is in pain and treat accordingly
      C)
      Maintain the room temperature at 65F
      D)
      Provide the patient ice chips as requested
    Page 2 of 20

    Exam Review

    1. The nurse is caring for a patient who is susceptible to infection. Which instruction will nurse include in an educational session to decrease the risk of infection?
      A)
      Teaching the patient to select nutritious foods
      B)
      Teaching the pattern about the effects of alcohol
      C)
      Teaching the patient about fall prevention
      D)
      Teaching the patient to take a temperature
    2. Which interventions utilized by the nurse will indicate the ability to recognize a localized inflammatory response?
      A)
      Vigorous range-of-motion exercises
      B)
      Orient to date, time, and peace
      C)
      Turn, cough and deep breathe
      D)
      Rest, ice and elevation
    3. The nurse is providing an educational session for a group of preschool workers. The nurse reminds the group of preschool workers. The nurse reminds the group about the most important thing to do to prevent the spread of infection. Which information did the nurse share with the preschool workers?
      A)
      Wash their hands between each interaction with children
      B)
      Clean the toys every afternoon before putting them away
      C)
      Suggest that parents provide a multivitamin to the children
      D)
      Encourage preschool children to eat a nutritious diet
    4. The nurse is caring for a patient with an incision. Which actions will best indicate an understanding of medical and surgical asepsis for a sterile dressing change?
      A)
      Donning clean googles, gown, and gloves to dress the wound
      B)
      Donning sterile gown and gloves to remove the wound dressing
      C)
      Utilizing clean gloves to remove the dressing and clean supplies for the new dressing
      D)
      Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing
    Page 3 of 20

    Exam Review

    1. Which nursing action will most likely increase a patient's risk for developing a health care-associated infection?
      A)
      Uses a sterile bottled solution more than once within a 24-hour period
      B)
      Uses a clean technique for inserting a urinary catheter
      C)
      Uses a cleaning stroke from the urinary meatus toward the rectum
      D)
      Uses surgical aseptic technique to suction airway
    2. The nurse is providing an education session to an adult community group about the effects of smoking on infection. Which information is most important for the nurse to include in the educational session?
      A)
      Smoke from tobacco products clings to your clothing and hair.
      B)
      Smoking affects the cilia lining the upper airways in the lungs
      C)
      Smoking tobacco products can be very expensive
      D)
      Smoking can affect the color the color of the patient's fingernails
    3. The nurse asks a patient the following series of questions: "Describe for me how much you exercise each day." "How do you tolerate the exercise?" "Is the amount of exercise you get each day the same, less, or more than what you did a year ago?" This series of questions would likely occur during which phase of a patient-centered interview?
      A)
      Orientation
      B)
      Working phase
      C)
      Data interpretation
      D)
      Termination
    4. 16) A nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient's legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of:
      A)
      Reflection
      B)
      Clinical inference
      C)
      Cue
      D)
      Validation
    Page 4 of 20

    Exam Review

    1. In preparing to collect a nursing history for a patient admitted for elective surgery, which of the following data are part of the review of present illness in the nursing health history?
      A)
      Current medications
      B)
      Patient expectations of planned surgery
      C)
      Review of patient's family support system
      D)
      History of allergies
      E)
      Patient's explanation for what might be the cause of symptoms that require surgery
    2. A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical record indicates tympanic temperatures of 38.7°C (101.6°F) at 0400, 36.6°C (97.9°F) at 0800, 36.9°C (98.4°F) at 1200, 37.6°C (99.6°F) at 1600, and 38.3°C (100.9°F) at 2000. How would the nurse describe this pattern of temperature measurements?
      A)
      Usual range of circadian rhythm measurements
      B)
      Sustained fever pattern
      C)
      Intermittent fever pattern
      D)
      Resolving fever pattern
    3. Which of the following patients are at most risk for tachypnea? (Select all that apply.)
      A)
      Patient just admitted with four rib fractures
      B)
      Woman who is 9 months pregnant
      C)
      A patient admitted with hypothermia
      D)
      Postoperative patient waking from general anesthesia
      E)
      Three-pack-per-day smoker with pneumonia
    4. The nurse is caring for a patient who has an elevated temperature. Which principle will the nurse consider when planning care for this patient?
      A)
      Hyperthermia and fever are the same thing
      B)
      Hyperthermia occurs when the body cannot reduce heat production
      C)
      Hyperthermia is an upward shift in the set point
      D)
      Hyperthermia results from a reduction in thermoregulatory
    Page 5 of 20

    Exam Review

    1. The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within normal limits. Which finding will help the nurse determine the cause of the patient's low heart rate?
      A)
      The patient has possible hemorrhage or bleeding
      B)
      The patient has a fever
      C)
      The patient has chronic obstructive pulmonary disease (COPD)
      D)
      The patient has calcium channel blockers or digitalis medication prescriptions
    2. The nurse is caring for a patient who has a temperature of 100.4F (38C). The patient's last two temperature readings were 98.6 F (37) and 96.8. Which action will the nurse take?
      A)
      Be aware that temperatures this high are harmful and affect patient safety
      B)
      Encourage the patient to move around to increase muscular activity
      C)
      Wait 30 minutes and recheck the patient's temperature
      D)
      Assume that the patient has an infection and order blood cultures
    3. The patient is being admitted to the emergency department following a motor vehicle accident. The patient's jaw is broken with several broken teeth. The patient is ashen, has cool skin, and is diaphoretic. Which route will the nurse use to obtain an accurate temperature reading?
      A)
      Oral
      B)
      Axillary
      C)
      Tympanic
      D)
      Temporal
    4. The patient is found to be unresponsive and not breathing. Which pulse site will the nurse use?
      A)
      Brachial
      B)
      Apical
      C)
      Carotid
      D)
      Radial
    Page 6 of 20