Exam Review

The nurse is caring for a client who is overweight and easily becomes diaphoretic. In response to this finding, which assessment(s) should the nurse include while assisting the client with personal care? (Select all that apply)(SATA)
A)Assess skin folds of perineal area.
B)Palpate mucus membranes for cracks.
C)Observe skin under the breasts.
D)Monitor color of nailbeds.
E)Check skin for unusual bruising.
The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?
A)Release the manometer valve immediately.
B)Inflate blood pressure cuff to 120 mm Hg.
C)Document the absence of the radial pulse.
D)Record a palpable systolic pressure of 90 mm Hg.
A client on a mechanical soft diet is experiencing constipation and asks the nurse for a glass of prune juice. After auscultating decreased bowel sounds, which action should the nurse implement?
A)Advance to a regular diet.
B)Offer to warm the prune juice.
C)Initiate bowel training protocol.
D)Restrict oral fluid intake.
A client diagnosed with primary open angle glaucoma received a prescription for miotic eye drops. Which instruction should the nurse plan to include in this client's teaching?
A)"Administer the medication directly on the cornea."
B)"Squeeze your eye closed after administering the drops."
C)"Wash your hands after each administration of eye drops."
D)"Do not allow the dropper bottle to touch the eye."

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Exam Review

When initiating oxygen per mask to a client who is short of breath, the nurse hears a loud hissing sound after inserting the flowmeter into the wall outlet. Which should the nurse do next?
A)Attach the flowmeter to a humidification canister.
B)Assess the position of the mask on the client's face.
C)Adjust the flow rate to the prescribed liters per minute.
D)Release and reinsert the flowmeter in the wall outlet.
The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?
A)Uses sterile gloves when handling body fluids.
B)Keeps a pair of gloves in uniform pocket.
C)Dons sterile gloves when caring for clients with HIV.
D)Puts on new gloves when entering a client's room.
The palliative care nurse receives a consult for a terminally ill client in the intensive care unit. The client is weak, mouth breathing, and refusing anything to eat or drink. Which intervention should the nurse include in the plan of care?
A)Record the client's daily weight.
B)Maintain in high Fowler's position.
C)Report any change in urine color.
D)Keep mucous membranes moist.
When administering a new medication to a client, the nurse logs in the electronic medication administration record (eMAR). Which action should the nurse take next?
A)Remove the medication from the unit dose packaging while verifying the dose.
B)Reconcile the medication to be administered with the initial client prescription.
C)Scan the medication barcode to document administration on the eMAR.
D)Verify client's identification by scanning the barcode on the armband.

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Exam Review

A client is being admitted to the unit with a varicella zoster virus infection. Which room should the charge nurse assign to the client?
A)A private room with both standard and droplet precautions.
B)A private room with both contact and airborne precautions.
C)A semi-private room with a roommate who has the same diagnosis and contact precautions.
D)A semi-private room with a roommate who has the same diagnosis and airborne precautions.
The nurse educators on a cardiovascular unit of a health care facility are creating a social media project that addresses improving outcomes for clients with heart failure. Which action should the nurses implement to protect client privacy?
A)Respect all copyright laws when adding website content.
B)May use information from the client's relatives instead.
C)Implement full disclosure policy especially when giving example.
D)Remove client identifying information of those who participate.
Which action should the nurse implement when inserting an indwelling catheter for an uncircumcised male client?
A)Advance the catheter before inflating balloon.
B)Position the sterile field even with the nurse's hips.
C)Clean the urinary meatus before retracting the foreskin.
D)Use a swab to wipe the meatus in back-and-forth motions.
The nurse observes the unlicensed assistive personnel (UAP) securing a client’s wrist restraints to the bedside rails. Which action is most important for the nurse to implement?
A)Demonstrate proper securing of the restraints.
B)Complete an adverse occurrence/incident report.
C)Initiate the facility’s restraint flow sheet.
D)Ensure that the restraints are not too tight.

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Exam Review

The nurse is documenting wound care in a client's electronic medical record (EMR) when the computer system shuts down. Which action should the nurse implement first?
A)Wait for notification that the system has been rebooted.
B)Print electronic medical record (EMR) from backup server.
C)Identify information as late entry in the record.
D)Notify information services department of the situation.
The nurse assesses a client who has a nasal cannula delivering oxygen at 2 liters/minute. To assess for skin damage related to the cannula, what areas should the nurse observe? (Select all that apply)(SATA)
A)Around the nostrils.
B)Bridge of the nose.
C)Over the cheeks.
D)Tops of the ears.
E)Across the forehead.
In planning the turning schedule for a bedfast client, it is most important for the nurse to consider which assessment finding?
A)A Braden risk assessment scale rating score of ten.
B)Warm, dry skin with a fever of 100.0° F (37.8° C).
C)Hypoactive bowel sounds with infrequent bowel movements.
D)4+ pitting edema of both lower extremities.
The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?
A)Risk for infection.
B)Self care deficit.
C)Risk for impaired skin integrity.
D)Impaired physical mobility.

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Exam Review

The mother of two toddlers who was recently divorced is scheduled for breast augmentation. During the day surgery admission process, the client tells the nurse that she has not executed a living will, but does not want to be resuscitated or put on any mechanical breathing machines. Which action(s) should the nurse take? (Select all that apply)(SATA)
A)Explain the benefit of executing an advanced directive.
B)Document the client's statement on the admission form.
C)Encourage the client to execute a will that identifies a guardian for her children.
D)Flag the client's record with "do not resuscitate".
E)Notify the client’s next of kin prior to surgery.
When assessing a client with a serum potassium level of 2.5 mEq/L (2.5 mmol/L), which intervention is most important for the nurse to implement?
A)Observe color and amount of urine.
B)Compare muscle strength bilaterally.
C)Determine apical heart rate and rhythm.
D)Assess strength of deep tendon reflexes.
The nurse enters a client’s room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?
A)While touching the client’s forearm, asks, "Would you like to talk about it?"
B)Gives the client a hug and says, "It is okay to cry when you are sad"
C)"I am sorry to disturb you at a difficult time. This can wait until later."
D)"This is a bad time. I can see you are upset. I can come back later."
A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?
A)Administer a PRN sedative prescription.
B)Apply wrist restraints to prevent wandering.
C)Leave the door to the client's room open slightly.
D)Provide a back rub at bedtime.

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