EXIT EXAM PRACTICE #1
Question 1
The ambulatory care nurse is working with a 22-year-old client who has been diagnosed with pelvic inflammatory disease (PID). The nurse incorporates which item in a teaching plan for this client?
Avoid frequent douching.
Undergarments made of nylon are best.
Intrauterine devices are a good birth control method.
It is necessary to change sanitary pads only every 8 hours.
Question 2
The registered nurse (RN) is educating a new RN on the "law and order orientation" found in level 2 of Kohlberg's theory of moral development. Which statement by the new RN indicates that the teaching has been effective?
"An example of this is: If I skip down the hall, will the teacher be mad at me?"
"An example of this is: We will spend time talking about the activities for the week."
"An example of this is: I don't like it when you yell while I am talking to my friend. Here are some activities to do until I am finished talking."
"An example of this is: If you do all of your classwork today without bothering others in the class, you will get an extra 'seed' for your good behavior garden."
Question 3
The nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which is the most appropriate activity for this child?
A radio
A sports video
Large picture books
Crayons and a coloring book
Question 4
A clinic nurse is preparing to evaluate the peripheral vision of a client by the confrontational method. Which statement demonstrates that the client correctly understands the instructions for the test?
"I will tell you when I see the colored dots."
"I will tell you when I see the flash of bright light."
"I will tell you when the small object is in my visual field."
"I will tell you when the blocks and shapes are in my visual field."
Question 5
The nurse is performing an abdominal assessment and inspects the skin on the client's abdomen. Which assessment technique would the nurse perform next?
Palpate the abdomen for size.
Palpate the liver at the right rib margin.
Listen to bowel sounds in all four quadrants.
Percuss the right lower abdominal quadrant.
Question 6
A nursing student is asked about the procedure used to elicit Homans' sign. Which response by the student indicates an understanding of this assessment technique?
"I will ask the client to raise the legs up to the waist and then to lower the legs slowly."
"I will ask the client to raise the legs and to try to lower them against pressure from my hand."
"I will ask the client to extend the legs flat on the bed, and I will gently dorsiflex the foot forward."
"I will ask the client to extend the legs flat on the bed, and I will grasp the foot and sharply extend it backward."
Question 7
The nurse is preparing to test the visual acuity of a client using the Snellen Chart. The nurse educates the client about the procedure. Which statement by the client indicates that the teaching has been effective?
"Stand 10 ft (3 meters) from the chart and cover 1 eye."
"Stand 20 ft (6 meters) from the chart and cover 1 eye."
"Stand 30 ft (9 meters) from the chart and read the largest line on the chart."
"Stand 40 ft (12 meters) from the chart and read the largest line on the chart."
Question 8
The nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which areas helpful in assessing for pallor or cyanosis? Select all that apply.
Sclera
Tongue
Nail beds
Elbows and Knees
Mucous Membranes
Question 9
The clinic nurse is preparing to perform a Romberg test on a client being seen in the clinic. The nurse would perform this test for the purpose of determining which status?
The client's ability to ambulate
The intactness of the tympanic membrane
The intactness of the retinal structure of the eye
The functional status of the vestibular apparatus in the inner ear
Question 10
The nurse is preparing to perform a Weber test on a client. The nurse would obtain which item needed to perform this test?
A tuning fork
A stethoscope
A tongue blade
A reflex hammer
Question 11
A nursing student is performing a respiratory assessment on an adult client and is assessing for tactile fremitus. Which action by the nursing student indicates a need for further teaching?
Palpating over the lung apices in the supraclavicular area
Asking the client to repeat the word ninety-nine during palpation
Palpating over the breast tissue to assess and compare vibrations from one side to the other
Comparing vibrations from one side to the other as the client repeats the word ninety-nine
Question 12
The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique would the nurse implement to test the motor function of this nerve?
Ask the client to puff out the cheeks.
Separate the client's jaw by pushing down on the chin.
Place a small amount of sugar on the client's tongue and ask them to identify the taste.
Ask the client to rotate the head forcibly against resistance applied to the side of his or her chin.
Question 13
The nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform which action to obtain the assessment data?
Turn the flashlight on directly in front of the eye and watch for a response.
Ask the client to follow the flashlight through the six cardinal positions of gaze.
Instruct the client to look straight ahead, and then shine the flashlight from the temporal area to the eye.
Check pupil size, and then ask the client to alternate looking at the flashlight and the examiner's finger.
Question 14
The nurse is testing a client for astereognosis. The nurse would ask the client to close the eyes and perform which action?
Identify an object placed in the client's hand.
Identify three numbers or letters traced in the client's palm.
State whether one or two pinpricks are felt when the skin is pricked bilaterally in the same place.
Identify the smallest distance between two detectable pinpricks, made with two pins held at various distances.
Question 15
The long-term care nurse is performing assessments on several of the residents. Which are normal age-related physiological changes the nurse would expect to note? Select all that apply.
Increased heart rate
Decline in visual acuity
Decreased respiratory rate
Decline in long-term memory
Increased susceptibility to urinary tract infections
Increased incidence of awakening after sleep onset
Question 16
The nurse has instructed the client in the correct technique for breast self-examination (BSE). For a portion of the examination, the client will lie down. The nurse would teach the client to put the pillow in which location for self-examination of the right breast?
Under the left scapula
Under left shoulder
Under the right shoulder
Under the small of the back
Question 17
The nurse has provided dietary instructions to a client with renal calculi who must learn about the foods that yield an alkaline residue in the urine. The nurse determines that education was effective if the client chooses which selections from a diet menu?
Spinach salad, milk, and a banana
Chicken, potatoes, and cranberries
Peanut butter sandwich, milk, and prunes
Linguini with shrimp, tossed salad, and a plum
Question 18
The nurse has provided instructions to a client with a urinary tract infection regarding foods and fluids to consume that will acidify the urine. Which fluids would the nurse include in the client's teaching plan that will aid in acidifying the urine? Select all that apply.
Milk
Prune Juice
Apricot Juice
Cranberry Juice
Carbonated Drinks
Question 19
The nurse has provided instructions to a client regarding testicular self-examination (TSE). Which client statement indicates the need for further teaching regarding TSE?
"I know to report any small lumps."
"I examine myself every 2 months."
"I examine myself after I take a warm shower."
"I feel something like a cord in the back and going up."
Question 20
The nurse is participating in a health screening clinic and is preparing teaching materials about colorectal cancer. Which risk factor for colorectal cancer would the nurse include?
High-fiber, low-fat diet
Age older than 30 years
Distant relative with colorectal cancer
Personal history of ulcerative colitis or gastrointestinal polyps
Question 21
The nurse is assessing a client's muscle strength and notes that when asked, the client cannot maintain the hands in a supinated position with the arms extended and eyes closed. How would the nurse correctly document this finding on the medical record?
The client is demonstrating ataxia
The client is exhibiting pronator drift
The client appears to have nystagmus
Client examination reveals hyperreflexia
Question 22
A client's laboratory results indicate the serum calcium is 12 mg/dL (3 mmol/L) and the serum phosphorous is 2.1 mg/dL (0.697 mmol/L). Based on these findings, the nurse suspects imbalance of which hormone?
Thyroid Hormone
Parathyroid Hormone
Follicle-Stimulating Hormone
Adenocorticotropic Hormone
Question 23
Which of the following are characteristics of squamous cell carcinoma?
Irregularly shaped, pigmented papules or plaques
Pearly papule with a central crater and rolled, waxy borders
Small macules or papules with dry, rough, adherent yellow or brown scale
Firm, nodular lesion topped with a crust or with a central area of ulceration
Question 24
A client complains of chronic pruritus. Which diagnosis would the nurse expect to note documented in the client's medical record that would support this client's complaint?
Anemia
Hypothyroidism
Diabetes
Chronic Kidney Disease
Question 25
A client with a history of hypertension has been prescribed triamterene. The nurse determines that the client understands the effect of this medication on the diet if the client states to avoid which fruit?
Pears
Apples
Bananas
Cranberries
Question 26
The community health nurse is creating a poster for an educational session for a group of community members and will be discussing the risk factors associated with breast cancer. Which risk factors for breast cancer would the nurse list on the poster? Select all that apply.
Multiparity
Early Menarche
Early Menopause
Family History of breast cancer
High-dose radiation exposure to the chest
Previous cancer of the breast, uterus, or ovaries
Question 27
The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select all that apply.
Set the room temperature at a comfortable level
Remove distracting objects from the interviewing area
Place a chair for the client across from the nurses desk
Ensure comfortable seating at eye level for the client and nurse
Provide seating for the client so that the client faces a strong light
Ensure that the distance between the client and nurse is at least 7 feet
Question 28
Which types of shock should NOT receive fluids -- or fluids should be used with EXTREME caution? Select all that apply
Neurogenic
Septic
Cardiogenic
Anaphylactic
Question 29
For a patient who is experiencing multiple injuries , which sequence of medical or nursing management would the nurse identify as a priority?
Assess for head injuries, control hemorrhage, establish an airway, prevent hypovolemic shock
control hemorrhage, prevent hypovolemic shock, establish an airway, assess for head injuries
establish an airway, control hemorrhage, prevent hypovolemic shock, assess for head injuries
prevent hypovolemic shock, assessed for head injuries , establish an airway, control hemorrhage
Question 30
The nurse is caring for a client with increased intracranial pressure as a result of a head injury. The nurse would note which trend in vital signs if the intracranial pressure is rising?
Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure
Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure
Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure
Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure
Question 31
The nurse is planning the care of a patient with a TBI in the neurosurgical ICU. In developing the plan of care, what interventions should be a priority? (Select all that apply.)
Making nursing assessments
Setting priorities for nursing interventions
Anticipating needs and complications
Initiating rehabilitation
Ensuring that the patient regains full brain function
Question 32
The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures would the nurse include in planning for the client's safety? Select all that apply.
Padding the side rails of the bed
Placing an airway at the bedside
Placing the bed in the high position
Putting a padded tongue blade at the head of the bed
Placing oxygen and suction equipment at the bedside
Flushing the intravenous catheter to ensure that the site is patent
Question 33
A client is admitted to the emergency department with an open fracture of the right tibia. What intervention is most appropriate for this client?
Remove the client's shoes.
Place the client in a semi-Fowler's position.
Check the neurovascular status of the area distal to the extremity.
Apply a tourniquet above the area of bleeding and loosen it every 15 minutes.
Question 34
The nurse is giving a client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed touch-down of the affected leg. The nurse would tell the client to perform which action?
Advance the crutches along with both legs simultaneously.
Advance the crutches along with the right leg, and then advance the left leg.
Advance the crutches along with the left leg, and then advance the right leg.
Advance the left leg along with right crutch, and then the right leg and left crutch.
Question 35
The nurse is preparing for a client's postoperative return to the unit after a parathyroidectomy procedure. The nurse would ensure that which piece of medical equipment is at the client's bedside?
Cardiac monitor
Tracheotomy set
Intermittent gastric suction device
Underwater seal chest drainage system
Question 36
A client with liver dysfunction has low serum levels of fibrinogen and a prolonged prothrombin time (PT). Based on these findings, which actions would the nurse plan to promote client safety? Select all that apply.
Monitor serum potassium levels.
Weigh client daily, and monitor trends.
Monitor for symptoms of fluid retention.
Provide the client with a soft toothbrush.
Instruct the client to use an electric razor.
Monitor all secretions for frank or occult blood.
Question 37
A client has just undergone spinal fusion after experiencing herniation of a lumbar disk. The nurse would include which interventions in the plan of care to maintain client safety after this procedure? Select all that apply.
Use the overhead trapeze
Keep the head of the bed flat.
Place pillows under the length of the legs.
Use a logrolling technique for repositioning.
Assist the client with eating meals and drinking fluids.
Question 38
A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client?
Begin to teach relaxation techniques.
Encourage the client to discuss the assault.
Remain with the client until the anxiety decreases.
Place the client in a quiet room alone to decrease stimulation.
Question 39
When creating an assignment for a team consisting of a registered nurse (RN), a licensed practical nurse (LPN), and two assistive personnel (APs), which is the best client for the LPN?
A client requiring frequent temperature checks
A client requiring assistance with ambulation every 4 hours
A client on a mechanical ventilator requiring frequent assessment and suctioning
A client with a spinal cord injury requiring urinary catheterization every 6 hours