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    Exam Review

    1. A nurse is collecting data from a client who has a BMI of 29. The nurse should document that the client is in which of the following weight categories?
      A)
      Overweight
      B)
      Underweight
      C)
      Ideal body weight
      D)
      Obese
    2. A nurse is assisting with the care of a client who is experiencing dysphagia following a recent stroke. The nurse should initiate a referral to which of the following interprofessional team members?
      A)
      Occupational therapist
      B)
      Registered dietitian
      C)
      Respiratory therapist
      D)
      Speech-language pathologist
    3. A nurse is reviewing the medical record of a client who has a paralytic ileus. Exhibits Client is lethargic and reports thirst and frequent urination.  Bilateral breath sounds clear and present throughout. Drag words from the choices below to fill in each blank in the following sentence. The findings in the client's medical record indicate ▾ Hyperglycemia and ▾ dehydration.
      Dropdown 1:
      Option 1: Infection
      Option 2: Hyperglycemia
      Option 3: pneumothorax
      Dropdown 2:
      Option 1: Infection
      Option 2: dehydration
      Option 3: pneumothorax
    4. A nurse is reinforcing teaching about beginning an exercise program with an older adult client who is at risk for osteoporosis. Which of the following activities should the nurse recommend?
      A)
      Passive range-of-motion exercise
      B)
      Bowling
      C)
      Walking
      D)
      Jogging
    Page 1 of 17

    Exam Review

    1. A nurse is assisting with the care of a client. Exhibits Which of the following actions should the nurse take to promote the client's respiratory status? Select all that apply.
      (SATA)
      A)
      Encourage the client to splint the abdomen when coughing.
      B)
      Administer acetaminophen.
      C)
      Administer ondansetron.
      D)
      Remind the client to use the incentive spirometer five times per hr.
      E)
      Encourage the client to cough and deep breathe.
      F)
      Plan to ambulate the client 30 min after the next analgesic is administered.
    2. A nurse is caring for a client who is postpartum. Which of the following documentations should the nurse include in the client's health record?
      A)
      Client instructed on self-care needs.
      B)
      Episiotomy approximated. 3 cm (1.18 in) in length.
      C)
      Client drank adequate amounts of fluid with meals.
      D)
      Oral temperature elevated at 0800.
    3. A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply.)
      (SATA)
      A)
      Squeeze the client's finger until a blood drop forms.
      B)
      Prick the side of the client's finger.
      C)
      Elevate the client's hand above the level of the heart.
      D)
      Cleanse the client's finger with an iodine swab.
      E)
      Apply clean gloves.
    4. A nurse on a medical-surgical unit is caring for a postoperative client who reports difficulty sleeping due to noise. Which of the following interventions is appropriate for the nurse to implement?
      A)
      Turn off alarms on bedside monitoring equipment
      B)
      Avoid entering the client's room unless requested during the night.
      C)
      Conduct staff communications away from the client's room.
      D)
      Turn on the client's TV to distract from hallway noise.
    Page 2 of 17

    Exam Review

    1. A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?
      A)
      Bear weight on the unaffected leg.
      B)
      Stand with the crutch tips against the feet.
      C)
      Hold the arms straight when walking.
      D)
      Keep the crutches at the level of the axillae.
    2. A nurse is collecting data from a client who is immobile and has a potential deep-vein thrombosis. Which of the following findings should the nurse report to the provider?
      A)
      Calf swelling
      B)
      Bradycardia
      C)
      Clammy skin
      D)
      Tortuous veins
    3. A nurse is observing an assistive personnel (AP) provide postmortem care for a client prior to visitation by their loved ones. Which of the following actions by the AP requires intervention by the nurse?
      A)
      Gathering the client's personal belongings
      B)
      Closing the client's eyes
      C)
      Washing the client's face
      D)
      Removing the client's dentures from their mouth
    4. A nurse is assisting with the care of a client who has cancer that has metastasized. The client has decided to discontinue chemotherapy treatment. Which of the following responses should the nurse make?
      A)
      "Your quality of life will be compromised if you make this decision."
      B)
      "How will you discuss this decision with your loved ones?"
      C)
      "Don't worry. Everything will work out for you."
      D)
      "We should talk about your decision later."
    Page 3 of 17

    Exam Review

    1. A nurse is preparing to reinforce teaching with a client who has expressive aphasia. Which of the following actions should the nurse plan to take?
      A)
      Provide the teaching without expecting the client to respond.
      B)
      Determine the client's ability to use a communication board
      C)
      Speak with a loud voice while providing the information.
      D)
      Avoid the use of facial gestures during the instructions.
    2. A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
      A)
      Scrub the inside and outside of the inner cannula with a small brush.
      B)
      Wipe the inside of the inner cannula with a folded pipe cleaner.
      C)
      Cleanse the stoma site with 0.9% sodium chloride solution.
      D)
      Unlock and remove the inner cannula.
      E)
      Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
    3. A nurse is inserting an indwelling urinary catheter for a male client. After inserting the catheter 15 cm (6 in), the nurse feels resistance and no urine flows through the catheter. Which of the following actions should the nurse take?
      A)
      Apply lidocaine gel to the urethra.
      B)
      Twist the catheter gently.
      C)
      Inflate the catheter's balloon.
      D)
      Lower the penis to a 45° angle.
    4. A nurse is caring for a client who has a new prescription for a belt restraint. Which of the following actions should the nurse take?
      A)
      Apply the belt restraint over the client's gown.
      B)
      Tie the belt restraint to the side rail of the bed.
      C)
      Check the client's skin integrity every 4 hr.
      D)
      Make sure four fingers fit between the restraint and the client's body.
    Page 4 of 17

    Exam Review

    1. A nurse is preparing to administer medications to a client. Which of the following pieces of information should the nurse use as a client identifier?
      A)
      Photograph
      B)
      Medical diagnosis
      C)
      Age
      D)
      Room number
    2. A nurse is caring for an adult client who has a developmental disability. The client requires an emergency appendectomy, and the staff cannot reach the appointed guardian. Which of the following is an appropriate action for the nurse to take?
      A)
      Postpone the procedure until the staff contacts the guardian.
      B)
      Obtain consent from the client.
      C)
      Request that the provider sign the consent form.
      D)
      Prepare the client for surgery with implied consent.
    3. A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching?
      A)
      "A family member will need to witness my signature on my living will."
      B)
      1 need to create advance directives so that I can donate my organs."
      C)
      "I can name my sibling as my designee in my durable power of attorney for health care."
      D)
      "My advance directives can be enforced once my attorney approves them."
    4. A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse. "I'm not going to take this medication because it makes me sick and dizzy." Which of the following actions should the nurse take first?
      A)
      Return the medication to the medication cabinet.
      B)
      Notify the provider of the client's refusal.
      C)
      Document the refusal in the client's medical record.
      D)
      Inform the client of the potential consequences of their refusal
    Page 5 of 17

    Exam Review

    1. A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
      A)
      Grasp the outermost flap of the sterile kit while opening away from the body.
      B)
      Open the innermost lower flap of the sterile kit while standing away from the sterile field.
      C)
      Open each side flap of the sterile kit individually while pulling to the side.
      D)
      Prepare a dry work surface above the waist level.
      E)
      Open the outside cover of the sterile kit and remove the dust cover.
    2. A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
      A)
      Measure the intake and output of a client who has received furosemide.
      B)
      Assess the pain level of a client who has received acetaminophen.
      C)
      Reinforce teaching with a client about crutch-gait walking.
      D)
      Check a client's peripheral IV site for redness or swelling.
    3. A nurse is preparing to perform a fecal occult blood test of stool specimens for a client. Which of the following actions should the nurse plan to take?
      A)
      Repeat the test three times using the same stool specimen.
      B)
      Wear sterile gloves when handling the stool specimen.
      C)
      Have the client defecate into a bedpan that contains a small amount of water.
      D)
      Ensure that the stool specimen does not contain urine.
    4. A nurse is assisting with feeding a client who has had a stroke. Which of the following findings should the nurse identify as a manifestation of dysphagia?
      A)
      Rapid chewing
      B)
      Garbled voice
      C)
      Sneezing
      D)
      Increased hunger
    Page 6 of 17