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    Exam Review

    1. A client who works at a computer most of the working day comes to the clinic reporting pain in both hands that causes the client to awake during the night. Which action should the nurse implement to assess for carpal tunnel syndrome?
      A)Tap the client’s wrists to locate the pain
      B)Compare the capillary refill in the hands
      C)Determine the client’s sleeping position
      D)Apply firm pressure over the ulnar artery
    2. A client is admitted with sudden abdominal pain and possible acute pancreatitis. Which serum laboratory test result(s) should the nurse monitor? (Select all that apply)(SATA)
      A)Amylase
      B)Glucose
      C)Serum triglycerides
      D)Calcium
      E)White blood cell count
    3. A client with Addison’s disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum laboratory value?
      A)Platelets
      B)Albumin
      C)Glucose
      D)Serum electrolytes
    4. A client with acute abdominal pain, persistent nausea, and projectile vomiting is admitted to the hospital for observation. Acetaminophen is administered as prescribed for an oral temperature of 103°F (39.4°C), and an IV infusion of normal saline is initiated at 250 mL/hour. Which assessment finding should the nurse report to the healthcare provider (HCP) immediately?
      A)Severe headache with photosensitivity
      B)Right lower abdomen rebound tenderness
      C)Petechial hemorrhage under client’s eyes
      D)Dark green colored emesis
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    Exam Review

    1. The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which is the best initial nursing action?
      A)Measure the client’s intake and output
      B)Increase the flow of the bladder irrigation
      C)Provide additional oral fluid intake
      D)Administer a PRN dose of an antispasmodic agent
    2. A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the postanesthesia unit. Before selecting which medication to administer, which action should the nurse implement?
      A)Determine which prescription will have the quickest onset of action
      B)Ask the client to choose which medication is needed for the pain
      C)Document the client’s report of pain in the electronic medical record
      D)Compare the client’s pain scale rating with the prescribed dosing
    3. During a preoperative assessment phone call, a client reports taking several “pills” every day. Which response should the office nurse provide?
      A)Discuss with your healthcare provider which medications to take before surgery
      B)Bring copies of all your prescription records
      C)Bring all of your medication containers to your preoperative appointment
      D)Obtain a copy of your medication records from your healthcare provider (HCP)
    4. The nurse assesses an adult client 24 hours after a bowel exploration and formation of a sigmoid colostomy. Which assessment finding should be reported to the surgeon immediately?
      A)The stoma mucosa is purple in color
      B)The fecal matter is brown and has a solid consistency
      C)The stoma has streaks of bright red blood
      D)There are no bowel sounds in the left lower quadrant
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    Exam Review

    1. A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the nurse implement?
      A)Educate client on signs and symptoms of narcotic dependency
      B)Give maximum dosage when score reaches 10
      C)Administer opioid and non-opioid medication simultaneously
      D)Alternate IV and IM analgesic medications
    2. The nurse is evaluating a client for possible deep vein thrombosis (DVT). Which assessment should the nurse perform?
      A)Inspect for distention of peripheral veins
      B)Observe for change in breathing pattern
      C)Palpate the volume of pedal pulses
      D)Assess for inflammation of the calves
    3. The nurse reports that a client is at risk for a stroke based on which assessment finding?
      A)Palpable cervical lymph node
      B)Carotid bruit
      C)Nuchal rigidity
      D)Jugular vein distention
    4. A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client’s plan of care (POC)?
      A)Evaluate level of consciousness
      B)Continuous cardiac monitoring
      C)Perform passive range of motion
      D)Assess burn depth and extent
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    Exam Review

    1. Four days following an abdominal aortic aneurysm (AAA) repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?
      A)Elevate both lower extremities
      B)Administer a PRN diuretic as prescribed
      C)Evaluate edema of the lower extremities
      D)Assess distal pulses with a Doppler device
    2. The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment?
      A)Tenderness upon palpation and generalized erythema
      B)Thick skin plaques topped by silvery white scales
      C)Requires sunglasses because sunlight hurts eyes
      D)Brown, rough, greasy, wart-like papules on the face
    3. A client with an external fixation device for a fractured left femur is troubled with left foot pain. Which intervention should the nurse implement first?
      A)Assess peripheral pulses
      B)Administer PRN pain medication
      C)Observe the leg for swelling
      D)Auscultate blood pressure
    4. A client with suspected increased intracranial pressure (ICP) exhibits clinical manifestations of Cushing’s triad. Which assessment finding would the nurse expect to observe?
      A)Hypertension with widening pulse pressure, bradycardia, and irregular respirations
      B)Profuse diaphoresis and severe, pounding headache
      C)Reports of chest pain and shortness of breath
      D)Pain and a burning sensation upon urination and hematuria
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    Exam Review

    1. A client is admitted with possible methicillin-resistant Staphylococcus aureus (MRSA). Which interventions should the nurse include in the plan of care (POC)? (Select all that apply)(SATA)
      A)Place the client in contact precautions
      B)Administer vancomycin as prescribed
      C)Obtain a wound culture
      D)Monitor white blood cell count
      E)Ensure hand hygiene compliance
    2. A client with chronic kidney disease (CKD) missed dialysis yesterday to attend a funeral. The client’s spouse calls the home health nurse and reports that the client is lethargic and hard to arouse. Which instruction is most important for the nurse to provide?
      A)Apply the client’s home oxygen
      B)Take client to emergency department (ED)
      C)Ensure that the client avoids salt intake for the rest of the day
      D)Check for a thrill and bruit at the client’s dialysis access site
    3. Which instruction should the nurse include in the discharge teaching for a client who has gastroesophageal reflux?
      A)Encourage the client to lie down and rest after meals
      B)Instruct the client to use antacids only as a last resort
      C)Teach the client to elevate the head of the bed on blocks
      D)Remind the client to avoid high fiber foods
    4. A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cells (PRBCs). When notifying the healthcare provider (HCP), 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)Communicate the pretransfusion temperatures
      D)Begin the report by stating the client’s name and admitting diagnosis
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