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Exam (elaborations)

RN EXAM LAST VERSION EAQ 2022

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RN EXAM LAST VERSION EAQ 2022

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RN EXAM LAST VERSION EAQ 2022

1. A nurse in a pediatric unit is preparing to insert an IV catheter for 7-year-
old. Which of the following actions should the nurse take?
A. (Unable to read)
B. Tell the child they will feel discomfort during the catheter insertion.
C. Use a mummy restraint to hold the child during the catheter insertion.
D. Require the parents to leave the room during the procedure. - ANSWER: B. Tell
the child they will feel discomfort during the catheter insertion.

2. A nurse is caring for a client who has arteriovenous fistula Which of the
following findings should the nurse report?
A. Thrill upon palpation.
B. Absence of a bruit.
C. Distended blood vessels
D. Swishing sound upon auscultation. - ANSWER: B. Absence of a bruit.

3. A nurse is providing discharge teaching for a client who has an
implantable cardioverter defibrillator which of the following statements
demonstrates understanding of the teaching?
A. "I will soak in the tub rather and showering"
B. "I will wear loose clothing around my ICD"
C. "I will stop using my microwave oven at home because of my ICD"
D. "I can hold my cellphone on the same side of my body as the ICD" - ANSWER: B. "I
will wear loose clothing around my ICD"

4. A nurse is caring for a client who is at 14 weeks gestation and reports
feelings of ambivalence about being pregnant. Which of the following
responses should the nurse make?
A. "Describe your feelings to me about being pregnant"
B. "You should discuss your feelings about being pregnant with your
provider"
C. "Have you discussed these feelings with your partner?"
D. "When did you start having these feelings?" - ANSWER: A. "Describe your feelings
to me about being pregnant"

5. A nurse is planning care for a client who has a prescription for a bowel-
training program following a spinal cord injury. Which of the following actions
should the nurse include in the plan of care?
A. Encourage a maximum fluid intake of 1,500 ml per day.
B. Increase the amount of refined grains in the client's diet.
C. Provide the client with a cold drink prior to defecation.
D. Administer a rectal suppository 30 minutes prior to scheduled
defecation times. - ANSWER: D. Administer a rectal suppository 30 minutes prior to
scheduled
defecation times.

,6. A nurse is caring for a client who is in active labor and requests pain
management. Which of the following actions should the nurse take?
A. Administer ondansetron.
B. Place the client in a warm shower.
C. Apply fundal pressure during contractions.
D. Assist the client to a supine position. - ANSWER: B. Place the client in a warm
shower.

7. a nurse in an emergency department is performing triage for multiple
clients following a disaster in the community. To which of the following types
of injuries should the nurse assign the highest priority?
A. Below-the knee amputation
B. Fractured tibia
C. 95% full-thickness body burn
D. 10cm (4in) laceration to the forearm - ANSWER: A. Below-the knee amputation

8. a nurse manager is updating protocols for the use of belt restraints. Which
of the following guidelines should the nurse include?
A. Remove the client's restraint every 4hr
B. Document the client's condition every 15 min
C. Attach the restrain to the bed's side rails
D. Request a PRN restrain prescription for clients who are aggressive - ANSWER: B.
Document the client's condition every 15 min

9. A nurse is teaching an in-service about nursing leadership. Which of the
following information should the nurse include about an effective leader?
A. Acts as an advocate for the nursing unit.
B. (Unable to read) for the unit
C. Priorities staff request over client needs.
D. Provides routine client care and documentation. - ANSWER: A. Acts as an
advocate for the nursing unit.

10. A nurse is reviewing the laboratory findings of a client who has diabetes
mellitus and reports that she has been following her (unable to read) care.
The nurse should identify which of the following findings indicates a need to
revise the client's plan of care.
A. Serum sodium 144 mEq/
B. (Unable to read)
C. Hba1c 10 %
D. Random serum glucose 190 mg/dl. - ANSWER: C. Hba1c 10 %

11. A nurse in a provider's office is reviewing the laboratory results of a
group of clients. The nurse should identify that which of the following
sexually transmitted infections is a nationally notifiable infectious disease
that should be reported to the state health department?
A. Chlamydia

,B. Human papillomavirus
C. Candidiasis
D. Herps simplex virus - ANSWER: A. Chlamydia

12. A nurse is teaching a newly licensed nurse about therapeutic techniques
to use when leading a group on a mental health unit. Which of the following
group facilitation techniques should the nurse include in the teaching?
A. Share personal opinions to help influence the group's values
B. Measure the accomplishments of the group against a previous group
C. Yield in situations of conflicts to maintain group harmony
D. Use modeling to help the clients improve their interpersonal skills - ANSWER: D.
Use modeling to help the clients improve their interpersonal skills

13. A nurse is planning for a client who practices Orthodox Judaism. The
client tells the nurse that (Unable to read) Passover holiday. Which of the
following action should the nurse include in the plan of care?
A. Provide chicken with cream sauce.
B. Avoid serving fish with fins and scales.
C. Provide unleavened bread.
D. Avoid serving foods containing lamb. - ANSWER: C. Provide unleavened bread.

14. A nurse is caring for a client who has a pulmonary embolism. The nurse
should identify the effectiveness of the treatment when?
A. A chest x-ray reveals increased density in all fields.
B. The client reports feeling less anxious.
C. Diminished breath sounds are auscultated bilaterally
D. ABG results include Ph 7.48 PaO2 77 mm Hg and PaCO2 47 mm Hg. - ANSWER: B.
The client reports feeling less anxious.

15. A nurse in an emergency department is assessing a client who reports
ingesting thirty diazepam tablets (Unable to read) a respiratory rate of
10/min. After securing the client's airway and initiating an IV, which of the
following actions should the nurse do next.
A. Monitor the client's IV site for thrombophlebitis.
B. Administer flumazenil to the client.
C. Evaluate the client for further suicidal behavior.
D. Initiate seizure precautions for the client. - ANSWER: B. Administer flumazenil to
the client.

16. A nurse in an emergency department is caring for a client who reports
cocaine use 1hr ago. Which of the following findings should the nurse
expect?
A. Hypotension
B. Memory loss
C. Slurred speech
D. Elevated temperature - ANSWER: D. Elevated temperature

, 17. A nurse is assessing a newborn who has a blood glucose level of 30
mg/dl. Which of the following manifestations should the nurse expect?
A. Loose stools
B. Jitteriness
C. Hypertonia
D. Abdominal distention - ANSWER: Jitteriness

18. A nurse in a pediatric clinic is reviewing the laboratory test results of a
school age child. Which of the following findings should the nurse report to
the provider?
A. Hgb 12.5 g/dl
B. Platelets 250,000/mm3
C. Hct 40%
D. WBC 14,000/mm3 - ANSWER: D. WBC 14,000/mm3

19. A charge nurse is teaching a newly licensed nurse about clients
designating a health care proxy in situations that require a durable power of
attorney for heal care (DPSHC). Which of the following information should the
charge nurse include?
A. "The proxy should make health care decisions for the client regardless
of the client's ability to do so."
B. "The proxy can make financial decisions if the need arises."
C. "The proxy can make treatment decisions if the client is under
anesthesia."
D. "The proxy should manage legal issues for the client." - ANSWER: C. "The proxy
can make treatment decisions if the client is under anesthesia."

20. A nurse in the PACU is caring for a client who reports nausea. Which of
the following actions should the nurse take first?
A. Turn the client on their side.
B. Administer an analgesic
C. Administer antiemetic
D. Monitor the client's vital signs. - ANSWER: A. Turn the client on their side.

21. A nurse is caring for a client who has a history of depression and is
experiencing a situational crisis. Which of the following actions should the
nurse take first?
A. Confirm the client's perception of the event
B. Notify the client's support system
C. Help the client identify personal strengths
D. Teach the client relaxation techniques - ANSWER: A. Confirm the client's
perception of the event

22. A nurse is caring for a client who has bipolar disorder and is experiencing
acute mania. The nurse obtained a verbal prescription for restraints. Which
of the following actions should the nurse take?
A. Request a renewal of the prescription every 8 hr.
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