EXIT EXAM
1. A nurse is caring for a school-age child who is postoperative
and received morphine IV bolus to pain 10 min ago. Which of the
following findings is the nurse's priority?
a. Bradypnea
b. Sedation
c. Euphoria
d. Constipation
2. A nurse is planning to administer 2 units of packed RBCs to
an older adult who has anemia. Which of the following actions
should the nurse plan to take? SATA
a. Prime the infusion tubing with 0.45 NaCl
b. Infuse blood over 4 hr.
c. Don sterile gloves to prepare blood
administration set up
d. Assess the client's lung sounds before the
infusion
e. Verify with another nurse that the unit of blood is compatible with the
client's blood type
3. A nurse is planning care for a client who is scheduled to
receive a PICC in the arm. Which of the following
interventions is appropriate for the nurse to include in the
plan of care?
a. Administer sedation for the procedure
b. Measure the arm circumference above the insertion site daily.
c. Use gauze to secure an arm board to the involved extremity.
,d. Schedule an MRI post-procedure to verify placement
4.Which of the following clients should the nurse place near
the nurse’s station:
a. A client who is in Buck's traction
b. A client who has orthostatic hypotension
c. A client who has an open wound
d. A client who is on fluid restriction
5.The older client transferred from another facility. The
nurse notes ulcers on the coccyx andabrasions around both
wrists. Which of the following actions should the nurse take
to address suspicions of elder abuse?
a. Notify risk management
c. Inform the transferring agency of the client's condition
d. Privately interview the client about her condition
e. Contact the family regarding the client's condition
6. A client receiving intermittent enteral tube feedings.
Which of the following places theclient at risk for
aspiration?
a. History of GERD
b. Sitting in a high Fowler's position during the feeding
c. A residual of 65 mL 1 hr postprandial
d. Receiving a high osmolarity formula
7. Adverse effects of sertraline
a. Dry cough
b. Increased urinary frequency
c. Metallic taste in my mouth
d. Excessive sweating (pharm PQ. 53: serotonin syndrome)
8. Teaching a client undergoing radiation therapy who
has stomatitis. Which of the responses by the client
indicates an understanding of the teaching
a. "I should limit my intake of dairy products to prevent nausea.
b. "I should use a soft-bristle toothbrush to clean my teeth after meals."
c. "I should moisten my lips with lemon-glycerin swabs.
d. "I should gargle with an alcohol-based mouthwash to kill germs
9. The client was placed in seclusion and restraints.
Which of the following actions should thenurse plan
to take?
,a. Ensure that the prescription for restraints is renewed every 6 hr.
b. Have a provider evaluate the client in person within 1 hr.
c. Plan to monitor the client every 30 min while restrained
d. Complete a written record reading the seclusion and restraint every 2
hr
10. Client with acute glomerulonephritis. Which of the
following food choices should the nurse recommend?
(low in potassium, sodium, and protein)
a. Bagel
b. Banana
c. Eggs
d. Smoked salmon
11. The client asks about acupuncture to manage his
osteoarthritis pain. The nurse should identify which
of the following conditions is a contradiction for
receiving this treatment.
a. HTN
b. Herpes zoster
c. Obesity
d. Hypothyroidism
12.A nurse in an acute mental health care facility is prioritizing
care for multiple clients. Which of the following clients
should the nurse see first?
a. The client taking clozapine to treat schizophrenia and reports a sore
throat
b. The client has OCD and is upset about a change in their daily routine
c. The client has a narcissistic personality disorder and is mocking others
during group therapy
d. A client who has a depressive disorder and requires assistance
with ADLs
13.A nurse is caring for a client who has an implanted venous
access port. Which of the following should the nurse use to assess
the port:
a. An angiocatheter
b. A butterfly needle
c. A non-coring needle
d. A 25 gauge needle
14. A nurse is caring for a client who has pneumonia and tells the
, nurse, "I feel like an elephant is sitting on my chest" The client is
weak and unable to walk. After the nurse indicates chest pain
protocol which of the following is the priority diagnostic test?
a. PT and INR
b. 12 lead ECG
c. Chest X-ray
d. Serum potassium
15.A nurse is assessing the growth and development of a 3 /o child.
Which of the following questions should the nurse ask the parent to
determine If the child is exhibiting typical developmental
expectations?
a. "Can your child draw a stick figure?
b. "Can your child catch and throw a small ball?
c. "Can your child ride a tricycle?"
d. "Can your child name five colors?
16. A nurse is preparing to assess fetal heart tones for a client
who is at 12 weeks of gestation. Which of the following actions
should the nurse take?
a. Measure the fundal height to determine the placement of the
ultrasound stethoscope
b. Perform Leopold maneuvers before auscultating the FHR
c. Position the ultrasound stethoscope above the symphysis pubis to
assess the FHR
d. Place the client in a side-lying position before assessing the HR
17. A nurse is assessing a client who has a chest tube with a water
seal drainage system. Upon assessment, the nurse notes tidying in
the water seal. Which of the following is an explanation for the
tidying?
a. There is a loop of the tubing below the
drainage systemb. The system is working
properly
c. The lung has re-expanded
d. The tubing is partially obstructed by clots
18. A charge nurse on a medical surgical unit is assisting with the
emergency response plan following an external disaster in the
community in anticipation of multiple client admissions. Which of
the following current clients should the nurse recommend for early
discharge?
a. A client who is receiving heparin for DV
1. A nurse is caring for a school-age child who is postoperative
and received morphine IV bolus to pain 10 min ago. Which of the
following findings is the nurse's priority?
a. Bradypnea
b. Sedation
c. Euphoria
d. Constipation
2. A nurse is planning to administer 2 units of packed RBCs to
an older adult who has anemia. Which of the following actions
should the nurse plan to take? SATA
a. Prime the infusion tubing with 0.45 NaCl
b. Infuse blood over 4 hr.
c. Don sterile gloves to prepare blood
administration set up
d. Assess the client's lung sounds before the
infusion
e. Verify with another nurse that the unit of blood is compatible with the
client's blood type
3. A nurse is planning care for a client who is scheduled to
receive a PICC in the arm. Which of the following
interventions is appropriate for the nurse to include in the
plan of care?
a. Administer sedation for the procedure
b. Measure the arm circumference above the insertion site daily.
c. Use gauze to secure an arm board to the involved extremity.
,d. Schedule an MRI post-procedure to verify placement
4.Which of the following clients should the nurse place near
the nurse’s station:
a. A client who is in Buck's traction
b. A client who has orthostatic hypotension
c. A client who has an open wound
d. A client who is on fluid restriction
5.The older client transferred from another facility. The
nurse notes ulcers on the coccyx andabrasions around both
wrists. Which of the following actions should the nurse take
to address suspicions of elder abuse?
a. Notify risk management
c. Inform the transferring agency of the client's condition
d. Privately interview the client about her condition
e. Contact the family regarding the client's condition
6. A client receiving intermittent enteral tube feedings.
Which of the following places theclient at risk for
aspiration?
a. History of GERD
b. Sitting in a high Fowler's position during the feeding
c. A residual of 65 mL 1 hr postprandial
d. Receiving a high osmolarity formula
7. Adverse effects of sertraline
a. Dry cough
b. Increased urinary frequency
c. Metallic taste in my mouth
d. Excessive sweating (pharm PQ. 53: serotonin syndrome)
8. Teaching a client undergoing radiation therapy who
has stomatitis. Which of the responses by the client
indicates an understanding of the teaching
a. "I should limit my intake of dairy products to prevent nausea.
b. "I should use a soft-bristle toothbrush to clean my teeth after meals."
c. "I should moisten my lips with lemon-glycerin swabs.
d. "I should gargle with an alcohol-based mouthwash to kill germs
9. The client was placed in seclusion and restraints.
Which of the following actions should thenurse plan
to take?
,a. Ensure that the prescription for restraints is renewed every 6 hr.
b. Have a provider evaluate the client in person within 1 hr.
c. Plan to monitor the client every 30 min while restrained
d. Complete a written record reading the seclusion and restraint every 2
hr
10. Client with acute glomerulonephritis. Which of the
following food choices should the nurse recommend?
(low in potassium, sodium, and protein)
a. Bagel
b. Banana
c. Eggs
d. Smoked salmon
11. The client asks about acupuncture to manage his
osteoarthritis pain. The nurse should identify which
of the following conditions is a contradiction for
receiving this treatment.
a. HTN
b. Herpes zoster
c. Obesity
d. Hypothyroidism
12.A nurse in an acute mental health care facility is prioritizing
care for multiple clients. Which of the following clients
should the nurse see first?
a. The client taking clozapine to treat schizophrenia and reports a sore
throat
b. The client has OCD and is upset about a change in their daily routine
c. The client has a narcissistic personality disorder and is mocking others
during group therapy
d. A client who has a depressive disorder and requires assistance
with ADLs
13.A nurse is caring for a client who has an implanted venous
access port. Which of the following should the nurse use to assess
the port:
a. An angiocatheter
b. A butterfly needle
c. A non-coring needle
d. A 25 gauge needle
14. A nurse is caring for a client who has pneumonia and tells the
, nurse, "I feel like an elephant is sitting on my chest" The client is
weak and unable to walk. After the nurse indicates chest pain
protocol which of the following is the priority diagnostic test?
a. PT and INR
b. 12 lead ECG
c. Chest X-ray
d. Serum potassium
15.A nurse is assessing the growth and development of a 3 /o child.
Which of the following questions should the nurse ask the parent to
determine If the child is exhibiting typical developmental
expectations?
a. "Can your child draw a stick figure?
b. "Can your child catch and throw a small ball?
c. "Can your child ride a tricycle?"
d. "Can your child name five colors?
16. A nurse is preparing to assess fetal heart tones for a client
who is at 12 weeks of gestation. Which of the following actions
should the nurse take?
a. Measure the fundal height to determine the placement of the
ultrasound stethoscope
b. Perform Leopold maneuvers before auscultating the FHR
c. Position the ultrasound stethoscope above the symphysis pubis to
assess the FHR
d. Place the client in a side-lying position before assessing the HR
17. A nurse is assessing a client who has a chest tube with a water
seal drainage system. Upon assessment, the nurse notes tidying in
the water seal. Which of the following is an explanation for the
tidying?
a. There is a loop of the tubing below the
drainage systemb. The system is working
properly
c. The lung has re-expanded
d. The tubing is partially obstructed by clots
18. A charge nurse on a medical surgical unit is assisting with the
emergency response plan following an external disaster in the
community in anticipation of multiple client admissions. Which of
the following current clients should the nurse recommend for early
discharge?
a. A client who is receiving heparin for DV
