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    Exam Review

    1. A nurse is assessing an older adult client at a health fair. Which of the following statements by the client is the nurse's priority?
      A)"In the last day, I have had a severe headache and pain around my right eye."
      B)"I can't seem to get reading materials far enough away to see the words."
      C)"I've noticed that there is a gray ring around the colored part of my eye."
      D)"I'm having more difficulty telling the difference between blues and greens."
    2. A nurse is caring for a client who has just been admitted to the emergency department (ED). Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
      ✓Decrease environmental stimuli
      ✓Initiate neurological checks every 2 hr.
      ✓Meningitis
      ✓Vascular changes
      ✓Temperature
      Actions to Take
      ✕Prepare the client for surgery.
      ✕Administer gabapentin.
      ✓Decrease environmental stimuli
      ✓Initiate neurological checks every 2 hr.
      ✕Administer sumatriptan
      Potential Condition
      ✕Hydrocephalus
      ✕Migraine headache
      ✕Septic shock
      ✓Meningitis
      Parameters to Monitor
      ✓Vascular changes
      ✕Gait
      ✓Temperature
      ✕Bowel sounds
      ✕Lactate level
    3. A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII?
      A)Deviation of the tongue from midline
      B)Disequilibrium with movement
      C)Inability to smell
      D)Loss of peripheral vision
    4. A nurse is caring for a client who had a thoracentesis 2 hr ago. Which of the following findings should the nurse expect?
      A)Increased lung expansion
      B)Rapid, shallow respirations
      C)Crepitus at the puncture site
      D)Dry, nonproductive cough
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    Exam Review

    1. A nurse is caring for a client receiving total parenteral nutrition who weighs 160 lb. If the RDA of protein is 0.3 g/kg of body weight, how many grams of protein should the client receive daily? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
    2. A home health nurse is assessing a client who has COPD. Which of the following findings indicates the need for a referral for pulmonary rehabilitation?
      A)Clubbing of the fingers
      B)Pursed-lip breathing
      C)Dyspnea at rest
      D)Sa02; 92%
    3. A nurse is teaching a client who has diabetes mellitus about foot care. Which of the following instructions should the nurse include?
      A)"Wear cotton rather than nylon socks."
      B)"Use a heating pad to keep your feet warm at night."
      C)"Wear loose fitting slippers around the house"
      D)"Wash your feet twice per day with antibacterial soap and hot water."
    4. A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. The client reports bladder spasms and the nurse observes decreased urinary output. Which of the following actions should the nurse take?
      A)Decrease traction on the catheter
      B)Remove the indwelling urinary catheter.
      C)Administer ibuprofen 400 mg for pain relief.
      D)Flush the catheter manually with 0.9% sodium chloride.
    Page 2 of 5

    Exam Review

    1. A nurse is planning to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse plan to take?
      A)Attach the bag to the rail of the bed
      B)Collect a urine specimen from the drainage bag 1 hr after insertion.
      C)Secure the catheter to the client's inner thigh
      D)Raise the head of the bed to 45" prior to insertion.
    2. A nurse is providing discharge teaching to a client who will be self-administering insulin at home. Which of the following information should the nurse include regarding needle disposal?
      A)"You can discard needles in an empty bleach bottle with a lid."
      B)"Remove the needle from the syringe before you place it in the trash,"
      C)"Place your storage container in a recycle bin when it is full."
      D)"Secure the cap tightly over the needle before you discard it."
    3. A nurse is caring for a client who takes lisinopril for hypertension. Which of the following client statements indicates an adverse effect of the medication?
      A)“I seem to be bruising more easily,"
      B)"I have to urinate frequently."
      C)"I have a nagging, dry cough."
      D)"I have a heightened sense of taste."
    4. A nurse is preparing to infuse dextrose 5% in 0.45% sodium chloride 500 mL IV bolus over 4 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies, Do not use a trailing zero.)
    Page 3 of 5

    Exam Review

    1. A nurse is caring for an older adult client who is 1 hr postoperative following a transurethral resection of the prostate and is receiving continuous bladder irrigation. Which of the following findings should the nurse report to the provider?
      A)Pink-tinged urine
      B)Moderate pain
      C)Decreased urinary output
      D)Client urge to void
    2. A nurse is caring for a client who is 2 days postoperative following abdominal surgery and has a prescription for opioid analgesia. Which of the following actions should the nurse implement to help facilitate the client's recovery?
      A)Provide analgesic medication prior to physical activities
      B)Administer naloxone if the client's respiratory rate is greater than 24/min.
      C)Inform the client to monitor for loose stools while taking opioid analgesia
      D)Withhold analgesic medication unless the client reports pain.
    3. A nurse is caring for a client who has hypervolemia, which of the following is an expected assessment finding?
      A)Weight gain
      B)Bradycardia
      C)Hypotension
      D)Loss of skin turgor
    4. A nurse is caring for a client who has ulcerative colitis and was admitted to the medical-surgical unit for management of diarrhea. Which of the following food items should the nurse select for the client's breakfast tray?
      A)Fresh peaches
      B)Poached egg
      C)Oatmeal
      D)Whole grain toast
    Page 4 of 5

    Exam Review

    1. A nurse on a medical-surgical unit is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?
      A)Use a bed alarm
      B)Move client to a double room.
      C)Use chemical restraints at bedtime.
      D)Encourage participation in activities that provide excessive stimulation.
    2. A nurse is teaching a client who has burns to the upper body about positioning to prevent contractures. Which of the following information should the nurse include?
      A)"Keep your elbow in a flexed position."
      B)"Remain in a side-lying position”
      C)"Wear splints on your wrists."
      D)"Place a firm pillow under your head."
    3. A nurse is performing a skin assessment for a client who has been on bed rest for 1 week. The nurse notes reddened areas on the client's scapulae. Which of the following actions should the nurse take?
      A)Use hot water when cleaning the client's skin.
      B)Provide the client with high-protein meals.
      C)Place the client in a supine position.
      D)Gently massage the reddened areas.
    4. A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include?
      A)Request a prescription for a nightly sedative.
      B)Place the client's bed at the lowest height.
      C)Turn off all lights in the client's room at night.
      D)Assist the client with toileting at least once every 4 hr.
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