Nurse Moose
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    Exam Review

    1. Patient Data Exhibits Review was done of H and P, nurses' notes, and orders. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
      ✓Place a hydrocolloid dressing over the area
      ✓E
      ✓Stage 2 pressure injury
      ✓Nutritional intake
      ✓Skin integrity
      Actions to Take
      ✕Discontinue the continuous positive airway pressure (PAP) immediately
      ✓Place a hydrocolloid dressing over the area
      ✕Request a prescription for antibiotic ointment from the physician
      ✕Position the client on the left side only
      Potential Conditions
      ✕Unstageable pressure injury
      ✕Stage 1 pressure injury
      ✓Stage 2 pressure injury
      ✕Stage 3 pressure injury
      Parameters to Monitor
      ✓Nutritional intake
      ✕Temperature
      ✓Skin integrity
      ✕Deep tendon reflexes
    2. A nurse stops at a motor vehicle collision to provide help for a victim who is trapped in an overturned running vehicle. The nurse turns off the engine key, and asks the client to wiggle the fingers because the client's head is impinged on the roof and the neck is bent to the left shoulder. After Emergency Medical Services (EMS) arrive, the nurse reports that the victim is conscious, but is not able to talk, and then the nurse leaves the scene. Which legal action can be taken in this situation?
      A)Criminal assault and battery.
      B)Good Samaritan immunity.
      C)Negligent acts of omission.
      D)Abandonment of the victim.
    3. The nurse is assessing a client who reports a 3 day history of vomiting and diarrhea and experiencing difficulty in tolerating oral fluids. Which urine specific gravity value would the nurse expect to see on initial testing? Reference Range: Urine Specific Gravity [1.005 to 1.03]
      A)1.025.
      B)1.035.
      C)1.005.
      D)1.015.
    4. The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?
      A)Completing discharge teaching to a client and family members.
      B)Offering therapeutic support and comfort to a grieving family.
      C)Obtaining clarification from a client's healthcare power-of-attorney.
      D)Reporting a change in a client's condition to the healthcare provider.
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    Exam Review

    1. An unlicensed assistive personnel (UAP) is assigned to feed a client who has received a prescription to institute droplet precautions for a bacterial meningitis infection. The UAP requests a change in assignment, reporting having not yet been fitted for a particulate filter mask. Which action should the nurse take?
      A)Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client.
      B)Before changing assignments, determine which staff members have fitted particulate filter masks.
      C)Advise the UAP to wear a standard face mask to obtain vital signs, and then get fitted for a filter mask before providing personal care.
      D)Send the UAP to be fitted for a particulate filter mask immediately so the UAP can provide care to this client.
    2. The nurse is caring for a client one-week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly?
      A)A well approximated incision site.
      B)Beefy red granulation tissue.
      C)Eschar and slough in the wound.
      D)Erythema and serosanguineous exudate.
    3. A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?
      A)Review the advanced directive document.
      B)Irrigate the nasogastric tube with water.
      C)Elevate the head of bed 45 degrees.
      D)Perform oropharyngeal suctioning.
    4. A client with chronic fecal incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which intervention should the nurse implement?
      A)Insert a rectal tube at specified intervals.
      B)Assist to a bedside commode 30 minutes after meals.
      C)Administer a glycerin suppository 15 minutes after meals.
      D)Encourage the use of incontinence briefs.
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    Exam Review

    1. The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client's attention on which focus?
      A)Positive external places.
      B)Tranquil sounds.
      C)Emotional reflection.
      D)Motivational phrases.
    2. Patient Data Exhibits The primary nurse went on break at 1845. The covering nurse gave insulin glargine and decided to manually document the dose but forgot to enter it into the electronic health record. The primary nurse came back from break and gave a second dose of insulin because of being unaware the covering nurse gave the ordered dose. What medication error prevention techniques would have helped to avoid this error? Select all that apply.(SATA)
      A)Compare the medication label to the order
      B)Use at least 2 client identifiers before administering a dose
      C)Document all medication in the electronic record as soon as it is given
      D)Involve and educate clients in medication administration
      E)Question unusually large or small doses F Double check all dosage calculations
    3. When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement? Reference Range: Potassium (3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]
      A)Observe color and amount of urine.
      B)Determine apical pulse rate and rhythm.
      C)Assess strength of deep tendon reflexes.
      D)Compare muscle strength bilaterally.
    4. A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours PO as needed for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)
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    Exam Review

    1. The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first
      A)Review the pain medications prescribed.
      B)Administer PRN oral pain medication.
      C)Ask the client what is causing the grimacing.
      D)Monitor the client's nonverbal behavior.
    2. The nurse is teaching a client about use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?
      A)Washes hands before handling the needle and syringe.
      B)Wears gloves to dispose of the needle and syringe.
      C)Dons a face mask before administering the medication.
      D)Removes needle before discarding used syringes.
    3. 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)Record a palpable systolic pressure of 90 mm Hg.
      B)Release the manometer valve immediately.
      C)Document the absence of the radial pulse.
      D)Inflate blood pressure cuff to 120 mm Hg.
    4. The healthcare provider prescribes a 24-hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?
      A)Start collecting the specimen with the next void.
      B)Empty the sample into the 24-hour container.
      C)Begin the collection the next day.
      D)Observe the sample for sediment.
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    Exam Review

    1. A client with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage?
      A)Regular exercise.
      B)Smoking cessation.
      C)Low fat diet.
      D)Stress reduction.
    2. 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)Ensure that the restraints are not too tight.
      B)Complete an adverse occurrence/incident report.
      C)Demonstrate proper securing of the restraints.
      D)Initiate the facility's restraint flow sheet.
    3. The nurse observes a practical nurse (PN) performing oral care on an unconscious client. Which action by the PN indicates to the nurse the need for additional training?
      A)Suctions secretion from the posterior pharynx.
      B)Places the client in a supine position.
      C)Tests for a gag reflex before performing oral care.
      D)Uses an oral airway to keep the teeth apart.
    4. Patient Data Exhibits Review H and P, nurse's notes, flow sheet, laboratory values, orders, and imaging studies. What times should the nurse measure vital signs? Select all that apply.(SATA)
      A)1400
      B)1200
      C)1800
      D)1600
      E)0800
      F)2000
      G)1500
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