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    Exam Review

    1. While caring for a client with full-thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the health care provider, the nurse should evaluate which laboratory value?
      A)Platelet count.
      B)Serum albumin.
      C)Neutrophil count.
      D)Blood pH level.
    2. To reduce the risk for pulmonary complications for a client with Amyotrophic Lateral Sclerosis (ALS), which interventions should the nurse implement? (Select all that apply)(SATA)
      A)Teach the client breathing exercises.
      B)Establish a regular bladder routine.
      C)Perform chest physiotherapy.
      D)Encourage use of incentive spirometer.
      E)Initiate passive range of motion exercises.
    3. A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important to report which assessment finding to the health care provider?
      A)Joint pain.
      B)Hematuria.
      C)Low grade fever.
      D)Muscle atrophy.
    4. The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?
      A)Has everyone at home already had varicella?
      B)Have the antifungal creams been effective?
      C)Do you have any dry patches on your feet and hands?
      D)Do your family members share combs and brushes?
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    Exam Review

    1. A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. The client asks the nurse for an alternative way to manage sleep apnea. Which recommendation should the nurse provide?
      A)Begin a weight loss program.
      B)Drink 1 to 2 glasses of wine at bedtime.
      C)Take sedatives prior to sleep.
      D)Sleep with the head of the bed flat.
    2. A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?
      A)Confirmation of the autoimmune disease process.
      B)Evidence of spread of the disease to the kidneys.
      C)Indication of the onset of joint degeneration.
      D)Representative of a decline in the client’s condition.
    3. An older client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. The client's family expresses concern about the client's nutritional status. How should the nurse respond to the family's concern?
      A)Demonstrate the use of visual scanning during meals to the client and family.
      B)Explain that weight loss will be reversed after the acute phase of the stroke has ended.
      C)Suggest that the family bring foods from home that the client enjoys eating.
      D)Encourage the family to offer to feed the client when she does not eat her entire meal.
    4. The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action about skin care indicates a need for further teaching?
      A)Wears clothing to cover the radiation site.
      B)Washes the radiation site with antibacterial soap and water.
      C)Applies prescribed lotions to the radiation site.
      D)Dries the area with patting motions after taking a shower.
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    Exam Review

    1. A client admitted to the emergency department with an acute exacerbation of peptic ulcer disease is vomiting and describing epigastric pain and nausea. After obtaining vital sign measurements, which prescription should the nurse implement first?
      A)Insert a nasogastric tube (NGT) and attach to low intermittent suction.
      B)Give a prescribed analgesic for temperature above 101°F (38.3° C).
      C)Place an indwelling urinary catheter and attach a bedside drainage unit.
      D)Send the client to x-ray for a flat plate of the abdomen.
    2. A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?
      A)Use incentive spirometer.
      B)Monitor urinary stream for decrease in output.
      C)Report when hematuria becomes pink tinged.
      D)Restrict physical activities.
    3. The nurse is caring for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. Which is the best initial nursing action?
      A)Cleanse the tongue and mouth with swabs.
      B)Administer a topical analgesic per protocol.
      C)Obtain a soft diet for the client.
      D)Encourage frequent mouth care.
      E)None
      F)None
    4. A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?
      A)Use incentive spirometer.
      B)Monitor urinary stream for decrease in output.
      C)Report when hematuria becomes pink tinged.
      D)Restrict physical activities.
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    Exam Review

    1. A client who fractured the right femur from a fall at home is placed in skeletal traction while awaiting surgery. When the client tells the nurse the need to urinate, which intervention should the nurse implement?
      A)Log roll the client and place adult disposable briefs beneath the client.
      B)Maintain traction while the client uses a urinal.
      C)Release the traction so the client can use a bedpan.
      D)Insert an indwelling urinary catheter preoperatively.
    2. Which admission assessment findings should the nurse document related to a client who has been diagnosed with Cushing’s syndrome?
      A)Husky voice and complaints of hoarseness.
      B)Warm, soft, moist, salmon-colored skin.
      C)Visible swelling of the neck, with no pain.
      D)Central-type obesity, with thin extremities.
    3. A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cells. When notifying the healthcare provider, which information should the nurse provide first using the SBAR (Situation, Background, Assessment, and Recommendation) communication process?
      A)Explain specific reason for urgent notification.
      B)Obtain a PRN prescription for acetaminophen for fever over 101° F (38.3° C).
      C)Preface the report by stating the client’s name and admitting diagnosis.
      D)Communicate the pre-transfusion temperatures.
    4. The nurse is caring for a client who is still experiencing light sedation after undergoing an emergency colectomy for bowel obstruction. Which postoperative pain intervention should the nurse implement first?
      A)Provide the first medication prescribed for pain management.
      B)Review medical records to obtain pain tolerance expectations.
      C)Wait until the client is awake before providing pain management.
      D)Attempt to obtain a self-report of pain level from the client.
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    Exam Review

    1. An adult client, a smoker, has had chronic obstructive pulmonary disease (COPD) for twelve years. When conducting discharge teaching, what should the nurse advise the client to avoid in order to prevent exacerbation of COPD?
      A)Exposure to persons with pneumonia or chickenpox.
      B)Excessive physical exertion and respiratory tract infections.
      C)Overdose of albuterol and alcohol consumption.
      D)Excessive bedrest and lack of exercise.
    2. A client asks the nurse for information about how to reduce risk factors for benign prostatic hyperplasia (BPH). Which information should the nurse provide?
      A)Obtain a prostate-specific antigen blood level test.
      B)Take vitamin supplements.
      C)Increase physical activity.
      D)Consume a high protein diet.
    3. Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?
      A)Isolate the client from other clients, family, and healthcare workers not wearing proper PPE.
      B)Report the COVID-19 result to the local health department according to CDC guidelines.
      C)Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.
      D)Explain to the client to inform others that they may have been potentially exposed in the last 14 days.
    4. A client with metastatic cancer reports a pain level of 10 on a pain scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which intervention is most important for the nurse to include in this client’s plan of care?
      A)Administer analgesics on a fixed and continuous schedule.
      B)Frequently evaluate the client’s pain.
      C)Replace transdermal analgesic patches every 72 hours.
      D)Monitor client for break-through pain.
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