Comprehensive Nursing Exam Preparation Guide, Exams of Nursing

Download Comprehensive Nursing Exam Preparation Guide and more Exams Nursing in PDF only on Docsity! AT EXAM EXIT/ QUESTIONS WITH COMPREHENSIVE CORRECT ANSWERS/ NEWEST EDITION 2024/ TESTED AND VERIFIED/ RATED A+/ PROFESSOR APPROVED A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent urinary tract infections? - ANSWER Draining urine from the tubing before ambulation will prevent back flow of urine into the bladder. A nurse is reviewing the medical record of a client who has heart failure. The nurse should identify which of the following lab results as an indication that the client has fluid volume excess? - ANSWER A BUN of 8 mg/dl is below the expected reference range of 10 to 20mg/dl. With fluid volume excess, the nurse should expect the client's BUN to be below the expected reference range due to hemodilution. A nurse is providing would care for a group of clients. Which of the following wounds should the nurse identify as healing by secondary intention? - ANSWER The nurse should identify a pressure injury and other wounds with edges that are not approximated as healing by secondary intention. A nurse is reinforcing teaching with a client about the use of crutches. Which of the following actions by the client indicates an understanding of the teaching? - ANSWER When ascending stairs, the client should first advance the unaffected leg. (UP to Heaven) A nurse is preparing to transfer a client from an acute care facility to a long-term facility. Which of the following information should the nurse plan to include in the transfer report. - ANSWER Resolved health conditions. The nurse should report both unresolved and resolved health conditions to promote continuity of care. A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit? - ANSWER Cool extremities Orthostatic hypotension Flat neck A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. Which of the following actions should the nurse plan to take? - ANSWER Administer an analgesic 30 min before starting the procedure. A nurse is assisting with the plan of care for four clients. Which of the following tasks should the nurse assign to an assistive personnel *(AP) - ANSWER The nurse should delegate assisting a client to get out of bed because this task requires little technical skill or judgement and is within the AP's range of function. A nurse is reviewing the vital signs of four clients. Which of the following findings requires further data collection by the nurse? - ANSWER A client who has a pulse rate of 110/min The client's heart rate is above the expected range of 60 to 100/min. A nurse is reinforcing teaching about hospice care measures with the family of a client who is dying. Which of the following statements by a member of the client's family indicates an understanding of the teaching? - ANSWER "We will keep her room cool to help her breathe better" A nurse is collecting data from an older client. Which of the following findings should the nurse report to the provider? - ANSWER The client reports urinary incontinence. A nurse is repositioning a client who has quadriplegia and is in the supine position. Which of the following actions should the nurse take to prevent client musculoskeletal injury? - ANSWER Internally rotate the client's hips by using a trochanter roll. The nurse should place trochanter rolls at the proximal end of each of the client's legs to maintain a neutral or internal rotation of the client's hips and to prevent external rotation of the hips, which can cause injury when the client is supine. A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care? - ANSWER Compare the client's pedal pulses bilaterally every 4 hr. The nurse should compare the pedal pulses bilaterally every 4 hours to check for adequate circulation for a client who has elastic bandages on their lower extremities. Cortisone, Corticosteroids - ANSWER K+, CBC, serum glucose Cholesterol-lowering statins - ANSWER Cholesterol, HDL, LDL, triglycerides, AST, ALT, CPK Iron Preparations - ANSWER CBC, Hgb & Hct Metabolic alkalosis - ANSWER slow and shallow respirations, dizziness, paresthesias, lightheadedness, cardiac dysrhymias, hyperactive reflexes, hypertonic muscles Mental status examination (MSE) - ANSWER Grooming long-term memory Affect Capillary refill - ANSWER less than 2 seconds A nurse identifies an extravasation of vesicant solution (a medication that injures tissues if it leaks from a vein) at a client's peripheral IV catheter's insertion site - ANSWER Stop the infusion disconnect the catheter from the tubing Attach a 3 - 5 ml syringe to the catheter Aspirate any IV solution from the catheter Acute kidney injury - ANSWER Hyperkalemia, hypermagnesemia MRSA - ANSWER Methicillin-Resistant Staphylococcus Aureus; an infectious disease caused by a pathogen that is resistant to many antibiotics such as penicillin Teaching to a client about advance directives - ANSWER enteral feeding tubes cardiopulmonary resuscitation durable power of attorney Levothyroxine - ANSWER separate calcium carbonate by 4 hr diverticulitis - ANSWER High fiber such as chicken or broccoli, high residue diet and avoid small seeds or husks Clients with OCD - ANSWER Difficulty relaxing rule-conscious behavior perfectionist behavior Echinacea - ANSWER stimulates the immune system Sterile procedure - ANSWER remove the bottle cap place the bottle cap inside up on clean surface pick up the bottle with the label facing his palm pour 1 to 2ml into a receptacle Seizure steps - ANSWER Remain with client and call for help Position the client safely in a lateral or side lying position Check the client from head to toe for injuries once the seizure is over. Orient and reassure client once they are awake. Treatment options for psoriasis - ANSWER Tar preparations corticosteroids UV light Findings to report for croup - ANSWER Drooling; can indicate epiglottis, which requires immediate attention Preparing to administer enteral feeding via NG tube - ANSWER Verify tube placement Check the residual feeding contents Administer feeding Evaluate client's tolerance to the feeding Infant who has a prescription for home oxygen and pulse oximetry monitoring. - ANSWER Rotate probe every 3 to 4 hours Notify if SaO2 readings over 95% Depressive disorder group therapy - ANSWER Decreasing feelings of isolation gaining support and encouragement from other group members Inserting large bore catheter into a large vein = Central Line - ANSWER Place tube in a basin of warm water Measure how far to insert the tube Lubricate the tip of the tube Insert the tube Obtain an x-ray Delegating tasks to AP - ANSWER Accompanying a client who has depression to occupational therapy Checking the position of a client who is in soft wrist restraints Sitting with a client who has alcohol use disorder who last drink was 4 days ago Stage III pressure ulcer - ANSWER Full-thickness tissue loss with no bone, tendon, or muscle visible Lamotrigine - ANSWER Withhold and Notify prescriber if skin rash occurs MMR vaccine - ANSWER first dose: 12-15 months second dose: 4-6 years Complication of TPN: Polyuria Adverse effect of clopidogrel - ANSWER black stools can indicate GI bleeding History of stroke - ANSWER observe for symmetry of the client's soft palate and uvula. Pt is at risk for aspiration and choking. Risks for postpartum hemorrhage - ANSWER What is precipitous labor? You may be wondering what, exactly, is precipitous labor? Basically, it's the experience of being in labor and then giving birth less than 3 hours after regular contractions start Providing hygiene care for a client who is immobilized - ANSWER Check the bed linens when removing them for personal items Keep the bath water's temp between 110F and 115F Shave the client's hair in the direction of the hair growth Assign to AP - ANSWER A client who has a history of congestive heart failure (stable) A young adult client who is 1 day postoperative following an appendectomy. A client who is 2 days postoperative following a laparoscopic cholecystectomy Multiple skin lesions from a varicella zoster infection. - ANSWER (HEPA) filter mask M.I - ANSWER Nausea Tachycardia Diaphoresis Sterile field for the insertion of a urinary catheter - ANSWER Perform hand hygiene Place the sterile package on the work surface Open the outermost flap of the package away from the body Open the side flaps of the package Open the innermost flap of the package Use the inner surface of the package as a sterile field Postoperative following a laryngectomy - ANSWER To aid in swallowing food, tip the chin before swallowing Swallow twice after each bite REMOVING PPE - ANSWER Gloves Goggles Gown Mask Complications of immobility - ANSWER Contractures of extremeties Crackles in the lungs pressure ulcers Steps of staple removal - ANSWER Remove the wound dressing Clean the skin along the sides of the incision Remove every other staple Steps Prior to Blood Transfusion - ANSWER Check and document the client's vital signs is correct. Verify that the blood type and Rh of the packed RBCs are checked by two nurses is correct. Provide the RN with IV tubing that has a filter is correct