EXIT EXAM - 11.11.23
Question 1
Your client has an allergy to both penicillin and latex. Which of these pathophysiological facts should you apply when you are providing to this client?
The sensitizing dose of penicillin can lead to anaphylaxis.
The second dose of penicillin can lead to distributive shock
You should be aware of the fact that about 10% of the population has an allergy to both penicillin and latex.
You should be aware of the fact that about 20% of the population has an allergy to both penicillin and latex.
Question 2
After your assessment of your client and the need to transfer your client from the bed to the chair, what is the best and safest way to transfer this paralyzed client when you suspect that you will need the help of another for the client’s first transfer out of bed?
Use a slide board.
Use a mechanical lift.
Use a gait belt.
Notify the client's doctor that the client cannot be safely transferred by you.
Question 3
Select the basic sterile asepsis procedures that are accurate. Select all that apply:
Sterile items ONLY are placed on the sterile field.
The nurse must keep the sterile field below waist level.
Coughing or sneezing over the sterile field contaminates the sterile field.
The nurse must maintain a 1/2 inch border around the sterile field that is not sterile.
Moisture and wetness contaminate the sterile field.
Sterile masks are used by staff and the client when a sterile field is being set up and/or maintained
Question 4
Select all of the cranial nerves that are accurately paired with its distinguishing characteristics and description. Again, select all that apply.
Olfactory Cranial Nerve: The sensory nerve that transmits the sense of smell to the olfactory foramina of the nose
Optic Cranial Nerve: This sensory nerve transmits the sense of vision from the retina to the brain.
Oculomotor Cranial Nerve: This motor and sensory nerve controls eye movements and visual acuity.
Trochlear Cranial Nerve: This motor nerve innervates eye ball movement and the superior oblique muscle of the eyes.
Abducens Cranial Nerve: This motor nerve innervates and controls the abduction of the eye using the lateral rectus muscle.
Facial Cranial Nerve: This motor nerve controls facial movements, some salivary glands and gustatory sensations from the anterior part of the tongue.
Glossopharyngeal Cranial Nerve: This sensory nerve This nerve gives us the sense of taste from the posterior tongue, and it also innervates the parotid glands
Question 5
A therapeutic milieu is:
A safe environment of care that is conducive to the prevention of medical errors
A client care area that provides personal privacy and the confidentiality of medical information
A European method of design and color to promote health and wellness.
The provision of a therapeutic environment of consistency to promote health.
Question 6
You routinely use the PQRST method to assess pain. The PQRST method consists of:
Pain level, the quality of the pain, the region or area of the pain, the severity of the pain, and the pain triggers
Precipitating factors, the quality of the pain, relief factors, the severity of the pain, and the pain triggers
Pain level, the quantitative numerical pain score, the region or area of the pain, the severity of the pain, and the pain triggers
•Pain level, the quantitative numerical pain score, the region or area of the pain, the severity of the pain, and the pain triggers
Question 7
Your client has a tube feeding. Which of the following commonly occurring complications of tube feedings can you prevent with the preventive measure that is coupled with it?
Constipation: The provision of a high fiber diet
Urinary pH changes: Encouraging ample oral fluid intake
Aspiration: Maintaining the client in at least a 30 degree angle
Aspiration: Maintaining the client in at least a 90 degree angle
Question 8
When you are monitoring your client who is now started on an intravenous antibiotic for an infection, you notice that the client is exhibiting signs of anaphylaxis. What is your first priority intervention?
Stop the intravenous flow
Slow down the intravenous flow
Notify the doctor
Begin CPR
Question 9
The administration of an intramuscular injection to a neonate should be given in the:
Gluteus maximus muscle.
Vastus lateralis muscle.
Deltoid muscle.
The sternocledomastoid muscle.
Question 10
Your client has been getting total parenteral nutrition for bowel rest for the last four days. During your assessment of the client today, your client tells you that their “chest hurts”. You assess that the client is also experiencing dyspnea. What is most likely occurring with this client?
Your client may be experiencing a fluid overload.
Your client may be experiencing an embolus.
Your client may be hyperglycemic.
Your client may have an inadvertent pneumothorax.
Question 11
You measure your 2 year old client’s vital signs as:
Respiratory rate: 32 breaths per minute
Pulse: 110 beats per minute
Blood pressure: 55/82
The mother asks you if these vital signs are normal. You should respond to this mother’s question by stating:
“The respiratory rate is a little too fast but the other vital signs are normal.”
“The pulse rate is a little too fast but the other vital signs are normal.”
“The blood pressure is a little low but the other vital signs are normal.”
“All of these vital signs are normal for a child that is 2 years of age.”
Question 12
Select the step of blood glucose level monitoring that is NOT accurate.
Turn the finger down so the blood will drop with gravity.
Wipe off the first drop of blood using sterile gauze.
Prick the side of the finger using the lancet.
Prick the pad of the finger using the lancet.
Question 13
You are caring for a client who has just had a thoracentesis. Which complication should you be aware of during the immediate post-operative period of time?
Infection
Pneumothorax
Aspiration
Dyspnea
Question 14
You measure your 5 year old client’s vital signs as:
Respiratory rate: 32 breaths per minute
Pulse: 100 beats per minute
Blood pressure: 85/55
The mother asks you if these vital signs are normal. You should respond to this mother’s question by stating:
“The respiratory rate is a little too fast but the other vital signs are normal.”
“The pulse rate is a little too fast but the other vital signs are normal.”
“The blood pressure is a little low but the other vital signs are normal.”
“All of these vital signs are normal for a child that is 2 years of age.”
Question 15
As a nurse preceptor, you are in the operating room with a student nurse. The client has received general anesthesia. The student nurse says, “Oh no, the general anesthesia is not working. The client is shaking and moving.” How should you respond to this student nurse?
“The client is having anesthesia awareness which is not good.”
“This often happens during stage 2 of general anesthesia.”
"The client needs more general anesthesia.”
“The client is having a seizure.”
Question 16
When caring for a female client who is being treated for hyperthyroidism, it is important to:
A. Provide extra blankets and clothing to keep the client warm.
B. Monitor the client for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy.
C. Balance the client’s periods of activity and rest.
D. Encourage the client to be active to prevent constipation.
Question 17
Nurse Len is teaching a group of women to perform BSE. The nurse should explain that the purpose of performing the examination is to discover:
A. Cancerous lumps
B. Areas of thickness or fullness
C. Changes from previous examinations
D. Fibrocystic masses
Question 18
Nurse Audrey is caring for a client who has suffered a severe cerebrovascular accident. During routine assessment, the nurse notices Cheyne- Stokes respirations. Cheyne-stokes respirations are:
A. Progressively deeper breath followed by shallower breaths with apneic periods.
B. Rapid, deep breathing with abrupt pauses between each breath.
C. Rapid, deep breathing and irregular breathing without pauses.
D. Shallow breathing with an increased respiratory rate.
Question 19
A male client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. Nurse Trish first response is to:
A. Call the physician
B. Place a saline-soaked sterile dressing on the wound
C. Take blood pressure and pulse
D. Pull the dehiscence closed
Question 20
The nurse is caring for Kenneth experiencing an acute asthma attack. The client stops wheezing and breath sounds aren’t audible. The reason for this change is that:
A. The attack is over.
B. The airways are so swollen that no air cannot get through.
C. The swelling has decreased.
D. Crackles have replaced wheezes.
Question 21
When performing oral care on a comatose client, Nurse Krina should:
Apply lemon glycerin to the client's lips at least every 2 hours
Brush the teeth with a client lying supine
Place the client in a side-lying position with the HOB lowered
Clean the clients mouth with hydrogen peroxide
Question 22
On morning assessment of your patient in room 2502 who has severe burns. You notice that fluid is starting to accumulate in his abdominal tissue. You note that his weight has not changed and his intake and output is equal. What do you suspect?
Third spacing
This is normal and expected after a burn and it is benign
Document this finding as non-pitting abdominal edema.
Intravascular compartment syndrome
Question 23
Which patient is at more risk for an electrolyte imbalance?
An 8 month old with a fever of 102.3 ‘F and diarrhea
A 55 year old diabetic with nausea and vomiting
A 5 year old with RSV
A healthy 87 year old with intermittent episodes of gout
Question 24
A patient is admitted to the ER with the following findings: heart rate of 110 (thready upon palpation), 80/62 blood pressue, 25 ml/hr urinary output, and Sodium level of 160. What interventions do you expect the medical doctor to order for this patient?
Restrict fluid intake and monitor daily weights
Administer hypertonic solution of 5% Dextrose 0.45% Sodium Chloride and monitor urinary output
Administer hypotonic IV fluid and administer sodium tablets.
No interventions are expected
Question 25
After obtaining an EKG on a patient you notice that ST depression is present along with an inverted T wave and prominent U wave. What lab value would be the cause of this finding?
Magnesium level of 2.2
Potassium level of 5.6
Potassium level of 2.2
Phosphorus level of 2.0
Question 26
You are taking a patient’s blood pressure manually. As you pump up the cuff above the systolic pressure for a few minutes you notice that the patient develop a carpal spasm. Which of the following is true?
The patient is having a normal nervous response to an inflating blood pressure cuff that is inflated above the systolic pressure
This is known as Trousseau’s Sign and is present in patients with hypocalcemia
This is known as Chvostek’s Sign
This is known as Trousseau’s Sign and is present in patients with hypocalcemia
Question 27
In report from a transferring facility you receive information that your patient’s Magnesium level is 1.2. When the patient arrives you are ordered by the doctor to administer Magnesium Sulfate via IV. Which of the following interventions takes priority?
Set-up bedside suction
Set-up IV Atropine at bedside due to the bradycardia effects of Magnesium Sulfate
Monitor the patient’s for reduced deep tendon reflexes and initiate seizure precautions
None of the above are correct
Question 28
Which patient is at most risk for fluid volume deficient?
A patient who has been vomiting and having diarrhea for 2 days.
A patient with continuous nasogastric suction.
A patient with an abdominal wound vac at intermittent suction.
All of the above are correct.
Question 29
A client with myocardial infarction is receiving tissue plasminogen activator, alteplase (Activase, tPA). While on the therapy, the nurse plans to prioritize which of the following?
Observe for neurological changes
Monitor for any signs of renal failure
Check the food diary
Observe for signs of bleeding
Question 30
What is the primary reason for administering morphine to a client with myocardial infarction?
To sedate the client
To decrease the client’s pain
To decrease the client’s anxiety
To decrease oxygen demand on the client’s heart