REVISED - EXIT EXAM STUDY 11.29.23
Question 1
The nurse is caring for a client with diabetes insipidus. Which interventions should the nurse include in the clients plan of care? Select all that apply.
Assess capillary blood glucose before every meal
Monitor neuro status
Provide zero sugar products and snacks
Keep ampule fluids at bedside
Assess for signs of hyperkalemia
Question 2
In order to prevent respiratory complications following an abdominal surgery, which post-op intervention is most important for the nurse to implement?
Administer pain meds as ordered
Keep the HOB elevated at the 45-degree angle
Help client sit in a chair as soon as their condition allows
Obtain an order for a daily chest X-Ray
Question 3
The nurse is caring for a client with nephrotic syndrome. Which observations require intervention? Select all that apply
Shares the room with a client being treated for pneumonia
Minimizes activity to conserve energy
Keeps potato chips and nuts at the bedside for frequent snacks
Keeps legs elevated while resting
Wears compression stockings while awake
Question 4
A client was brought to the ED after being hit in the head with a baseball bat and briefly loosing consciousness.
The client compains of a severe headache, and the client’s friend reports the client was initially fine and then become more and more confused since the injury, 2 hours ago.
Upon assessment the client has a scalp laceration and mild unilateral weakness.
Which additional assessment findings are most concerning to the nurse? Select all that apply.
Aniscoria
Ringing in the ears
Sensitivity to light
Respiratory rate of 9
Blood pressure of 150/75
Question 5
The nurse is caring for a client with nephrotic syndrome. The client tells the nurse “my body is cramping all over and it feels like my skin is too tight.” Which finding requires the nurse to notify the healthcare provider?
Foamy, bubbly urine
Swelling around the eyes bilaterally
Shifting dullness on abdominal exam
3+ pitting edema up to the inguinal folds
Question 6
Oxytocin IV at 0.5 mL/minute has been ordered for a Gravida 2 Para 1 client who presents to the labor and delivery unit for induction. What finding should the nurse report to the healthcare provider before initiating the infusion?
Client is at 42 weeks gestation.
Client has gestational diabetes.
Biophysical profile showed 4 limbs, one hand opening, and one episode of rhythmic breathing
Fetal heart tones are heard in the upper left quadrant.
Question 7
The nurse is concerned that a client with increased ICP is deteriorating. What did the nurse obserbe?
BP change from 140/80 to 160/70
Response to pain changed from extending arms straight by the side, to making fists and flexing arms over the chest
Opens eyes to speech instead of pain
Breathing rate doubles from 6 to 12
Question 8
The post-anesthesia care nurse prepares a client for discharge following a ureteral stent placement for urethral stricture. Which statements made by the client indicate an understanding of the discharge instructions? Select all that apply.
“I should monitor my urinary stream for a decrease in output.”
“I have been prescribed oxybutynin to prevent blood clots.”
“I should ensure adequate fluid and fiber intake to prevent pain.”
“I may experience flank pain with activity or burning when I urinate.”
“I should contact my provider if I see any sediment in my urine.”
Question 9
A client with pulmonary edema, secondary to left-sided HF is lethargic. ABGs show PaO2 of 41, SaO2 of 78%. Despite 100% oxygen therapy the client’s PaO2 does not improve. What action should the nurse take?
Administer furosemide as prescribed
Attach pulse oximeter to a different finger
Increase O2 flow rate
Start CPAP
Question 10
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 11
Which of the following should the nurse use to determine the effectiveness of treatment in a client with malnutrition?
BMI
Waist circumference
Serum Cholesterol, Triglycerides, LDL, and HDL levels
Albumin, preablumin, and transferrin levels
Question 12
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 13
A client with Addison disease experiences weakness, nausea, vomiting, and changes in vital signs. Which interventions should the nurse expect to be prescribed for this client? Select all that apply.
IV fluid replacement
Glucose monitoring
IV corticosteroid therapy
Potassium Supplements
Insulin Therapy
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
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 16
A 3-year-old client with a diagnosis of Duchenne Muscular Dystrophy is seen in the clinic. When taking the client’s history, which symptoms should the nurse expect the parent to describe? Select all that apply.
Decreased muscle tone
Clumsiness with frequent falls
Enlarged calf or thigh muscles
Walking on the toes or balls of the feet
Muscle weakness in the face and shoulders
Question 17
Which individuals are most likely to be at risk for development of psoriasis? Select all that apply.
An individual with darker skin
A client experiencing menopause
A client with a family history of the disorder
An individual who has experienced a significant amount of emotional distress
A client with a thin body frame who adheres to a regular exercise program
Question 18
Which of the following represents Ventricular Repolarization?
P Wave
Q Wave
U Wave
T Wave
Question 19
Which of the following represents Atrial Depolarization?
Q Wave
R Wave
P Wave
T Wave
Question 20
Which of the following are most likely to be noted in the nurses notes when documenting signs of Phlebitis in a patients IV? Select all that apply.
Edema around the IV site
Cool to touch
Warm to touch
Pain at IV sites
Vein appears inflamed
Question 21
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 22
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 23
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 24
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 25
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 26
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 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
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 29
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 30
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.