PN EXIT EXAM
• A nurse is caring for a client who has paranoid schizophrenia and believes that she is being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make? o "Why do you feel the staff is the FBI?" o "What makes you think the staff is following you?" o "The psychiatric staff is not FBI. They are here to help you." o "This must be very frightening for you. Let's talk more about it."
"The psychiatric staff is not FBI. They are here to help you."
• A nurse is reinforcing discharge teaching with a client who had a right total hip arthroplasty. Which of the following instructions should the nurse indicate? o "You should avoid crossing your legs for 3 months." o "You should avoid putting a pillow between your legs when in bed." o "You should avoid exercising for the next 6 weeks." o "You should avoid lying on your right side."
"You should avoid crossing your legs for 3 months."
A charge nurse in a long-term care facility is developing a performance improvement plan for an assistive personnel (AP). Which of the following actions should the nurse take when developing the plans? (Select all that apply) o Set a specific time frame for meeting performance goals b. Ask the nurse supervisor to review the plan • Base performance goals on peer comments • Request clients complete an evaluation about the AP's quality of care • Include the performance standard that the AP should meet
-Set a specific time frame for meeting performance goals b. Ask the nurse supervisor to review the plan - Include the performance standard that the AP should meet
A nurse on a mental health unit is planning care for a group of clients. Which of the following clients should the nurse see first? o A client who has bipolar disorder and is displaying flights of ideas o A client who has ADHD and has an inability to concentrate o A client who has schizophrenia and is having command hallucinations o A client who has depressive disorder and is withdrawn
A client who has schizophrenia and is having command hallucinations
A nurse is contributing to the development of an in-service program for mental health nursing staff. The nurse should include that the st • aff can medicate a client against his will, without a court hearing, in which of the following situations? o A client who has a serious mental illness o A client who is having difficulty making decisions about his treatment o A client for whom the benefits of the medication outweigh the risks o A client who is attempting to hurt himself or others
A client who is attempting to hurt himself or others
A charge nurse is discussing confidentiality requirements with a newly licensed nurse when sharing a client's medical information. Which of the following individuals should the charge nurse identify as appropriate with whom to share client information? o A nurse from another unit after a client commits suicide o A social worker who is assigned to an involuntary committed school-age client o A client's partner after the client reports intimate partner abuse o A client's employer who is concerned about safety due to substance use.
A social worker who is assigned to an involuntary committed school-age client
• A nurse is caring for an older adult client who reports pain and has a prescription for ketorolac 15 mg IM every 5 hr PRN. The client's current blood pressure is 114/55 mm Hg. Which of the following actions should the nurse take? o Request a prescription for a different pain medication for the client o Administer the medication to the client o Place the client on strict bedrest o Repeat the client's blood pressure measurement
Administer the medication to the client
• A nurse is assisting with the admission of a client who has pulmonary tuberculosis. Which of the following types of isolation precautions should the nurse include? o Airborne o Droplet o Protective o Contact
Airborne
nurse is reinforcing teaching with a client who is undergoing radiation therapy to the neck. Which of the following instructions should the nurse include in the teaching? Cleanse the neck by rubbing with a washcloth Limit fluid intake to 750 mL per day Eat three large meals each day Avoid exposing the neck to the cold
Avoid exposing the neck to the cold
nurse in a provider's office is collecting data from a client who has a history of hypertension during his annual physical examination. Which of the following findings should the nurse report to the provider immediately? o A 2 kg (4.4 lb) weight gain o Blurred vision o Potassium 3.6 mEq/L o Resumption of cigarette smoking
Blurred vision
A nurse is collecting data from a client who has a long leg cast that was applied 2 days ago. The client's foot is pale with a weak pedal pulse, and the client reports foot numbness. Which of the following actions should the nurse plan to take first? o Administer opioid pain medication o Apply an ice pack to the affected extremity o Check for pain with passive movement of the affected extremity o Elevate the affected extremity with several pillows
Check for pain with passive movement of the affected extremity
A nurse is assisting with the admission of a client who has Vancomycin- resistant enterococcus of the urine. Which of the following types of precautions should the nurse implement for this client? o Contact precautions o Droplet precautions o Airborne precautions o Protective precautions • A community health nurse is assistin
Contact precautions
• A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following fall precautions should the nurse plan to implement? o Create a schedule with an assistive personnel to do hourly rounding for the client o Apply rubber-soled slippers before ambulation o Move the bedside table with the client's personal items close to the bed o Determine the client's ability to use the call light
Determine the client's ability to use the call light
• A nurse is reinforcing dietary teaching with a client who has hyperemesis gravidarum. Which of the following instructions should the nurse include in the teaching? o Drink 240 mL ( 8 oz) of water with each meal o Eat a small meal every 2 to 3 hr o Avoid eating dairy products o Choose foods that are high in fat
Eat a small meal every 2 to 3 hr
nurse is caring for a client who suddenly develops chest pain and dyspnea. Which of the following actions should the nurse take first? o Place the client on bed rest o Obtain the clients ABG levels o Prepare the client for a ventilation-perfusion scan o Elevate the head of the client's bed
Elevate the head of the client's bed
• A nurse is reinforcing discharge teaching with the faculty of a client who has dependent personality disorder. Which of the following instructions should the nurse indicate in the teaching? o Maintain a verbal no-harm contract with the client o Assume responsibility for making the client's decisions o Encourage the client to be assertive o Limit the client's social interactions
Encourage the client to be assertive
• A nurse is assisting in the care of a client who has a fractured femur and is in Buck's traction, which of the following actions should the nurse take? o Clean the pin insertion sites on a daily basis o Ensure that the weights are hanging freely o Apply a 9 kg (20 lb) weight to the traction o Remove the weights while the client is eating
Ensure that the weights are hanging freely
• A community health nurse is assisting in the development of a brochure about hypertension. Which of the following actions should the nurse take? o Use a 12 point font size o Present information from complex to simple o Explain medical terminology using basic, one-syllable words o Write the information at an 8th-grade reading level
Explain medical terminology using basic, one-syllable words
nurse is reinforcing teaching on a client who has diabetes mellitus. Which of the following laboratory tests is the most accurate of blood glucose effective management? o Urine ketones o Glucose tolerance test o Glycosylated hemoglobin o Fasting blood glucose
Glycosylated hemoglobin
A nurse is using a glucometer to measure a client's capillary blood glucose level, Which of the following actions should the nurse take? o Test the first drop of blood that forms after the puncture o Wear sterile gloves o Keep the finger in a dependent position o Select the central tip of the finger
Keep the finger in a dependent position
A nurse is collecting data from a group of clients. Which of the following clients should the nurse identify as having xanthelasma?
Lady with eyes closed with nodule on eyelid
A nurse is caring for a client who recently gave birth to her first child. The newborn is crying and the client states, " I can't seem to do anything right. What should I do?" Which of the following responses should the nurse make? o "I'll take him back to the nursery, so you can get some rest." o "Babies need to cry soon after they are born to develop their lungs." o "Let me show you how to swaddle and cuddle him, then you try." o "If I turn him on his side, maybe he'll go back to sleep."
Let me show you how to swaddle and cuddle him, then you try."
A nurse is reviewing the home medications of a client who recently had transient ischemic attacks and is to begin taking clopidogrel. The nurse should instruct the client that which of the following over-the-counter medications interacts adversely with clopidogrel? Docusate sodium Ranitidine o Vitamin D3 o Naproxen
Naproxen
nurse is collecting data from a client who is 4 hr postoperative following a hemicolectomy. Which of the following findings is the nurse's priority, requiring immediate intervention? o Pain rating of 9 on a scale from 0 to 10 o Blood pressure 160/90 mm Hg o Oxygen saturation 89% o Abdominal dressing with a moderate amount of bright red drainage
Oxygen saturation 89%
A nurse is reviewing the medication record of a client who requires continuous oxygen saturation monitoring. Which of the following should the nurse identify as a factor that can affect the validity of the readings? o Calcium level 8.0 mg/dL o Peripheral vascular disease o Taking anticoagulant medication o IV access on the same extremity
Peripheral vascular disease
• A nurse is administering pancreatic enzymes to a client who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment? o Decreased sodium excretion o Improved absorption of vitamins B and C o Improved respiratory function o Reduced fat in the stools
Reduced fat in the stools
A nurse in a provider's office is reinforcing teaching about cigarette smoking with a client. Which of the following adverse effects should the nurse include in the teaching? o Decreased hemoglobin o Somnolence o Bradycardia o Decreased blood pressure
Somnolence
A nurse is caring for a client who has terminal cancer and has declined treatment. The nurse attempts to convince the client to reconsider his decision and discusses this attempt with the charge nurse. Which of the following actions should the charge nurse take? o Meet with the client's family to discuss treatment options o Perform a mental status examination to establish the client's competency o Ask the client if he has any financial concerns o Talk with the nurse about the need to support the client's decision
Talk with the nurse about the need to support the client's decision
charge nurse on a mental health unit is supervising a newly licensed nurse. For which of the following actions by the newly licensed nurse should the supervising nurse intervene? o Requests a client to assist with distributing lunch trays o Tells a client he will lose his phone privileges if he does not take his medication o Encourages a client to participate in a recreational therapy group o Places mechanical restraints on a client who is hitting another staff member
Tells a client he will lose his phone privileges if he does not take his medication
A nurse is caring for a client who has a recent diagnosis of a terminal illness. The nurse should identify which of the following as an indication of hopelessness? o The client wants to talk about the diagnosis with nursing staff o The client has a decreased energy level o The client makes funeral arrangements o The client requests a second opinion
The client has a decreased energy level
A nurse is placing a dressing over a stage 1 pressure ulcer on a client's heel, which of the following types of wound dressing should the nurse use? o Gauze packing o Calcium alginate o Transparent film o Adhesive strips
Transparent film
• A nurse is reviewing laboratory values for a client who is at 34 weeks of gestation. Which of the following findings should the nurse report to the provider? o Hgb 13.2 g/dL o Urine protein 3 plus o Fasting blood glucose 72 mg/dL o BUN 15 mg/dL
Urine protein 3 plus
• A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. Which of the following information should the nurse include in the teaching? o "You cannot drink fluids for 4 hours after the procedure." o "You will need to urinate before the procedure." o "You will have a leg bag to collect the urine." o "You will feel pressure when I inflate the catheter balloon."
You will need to urinate before the procedure."
• A nurse is reinforcing teaching with a client who has GERD and a prescription for ranitidine. Which of the following statements by the client indicates an understanding of the teaching? o "I have to remain upright for 1 hour after taking the medication." o "I should take this medication in the morning and at night." o "I should expect my tongue to turn black after I take this medication." o "I have to take this medication on an empty stomach."
o "I should take this medication in the morning and at night.
• A nurse is collecting data from an adolescent during an annual physical examination. Which of the following statements by the client is the nurse's priority? o "I'm angry with my girlfriend about an argument we had last night." o "I have anxiety when I'm in a large group." o "I'm not sleeping much because of all the homework I have." o "I would rather be alone than with my friends."
o "I would rather be alone than with my friends."
A nurse is reinforcing teaching with a client who has a new prescription for digoxin. Which of the following instructions should the nurse include in the teaching? o "Monitor for muscle weakness while taking the medication." o "Rotate injection sites when administering the medication." o "Withhold the medication if your pulse rate is above 100 beats per minute." o "Increase your intake of dietary fiber to increase absorption."
o "Monitor for muscle weakness while taking the medication."
A nurse is reinforcing discharge teaching with a client who has COPD and reports problems with maintaining adequate nutrition. Which of the following instructions should the nurse include? o "Self administer oxygen through your nasal cannula at 6 milliliters per minute during meals." o "Perform pulmonary hygiene 1 hour before meals." o "Drink at least 240 milliliters of water during each meal." o "Lie down for 30 minutes after eating."
o "Perform pulmonary hygiene 1 hour before meals."
A nurse is preparing to collect data on a preschooler. Which of the following behaviors by the child indicates that he is ready to cooperate? (Select all that apply) o Allows the nurse to touch him on the arm o Plays with toys in the examining room o c. Answers questions asked by the nurse o d. Makes eye contact with the nurse • Sits on his parent's lap when the nurse enters the room
o Allows the nurse to touch him on the arm o c. Answers questions asked by the nurse o d. Makes eye contact with the nurse
• A nurse is supervising an assistive personnel (AP) obtain supplies for a client who is on seizure precautions. Which of the following materials should the AP place in the client's room? o Oral suction equipment o Wrist restraints o Tongue depressor o Tracheostomy tray
o Oral suction equipment
