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West Coast University, Los Angeles NURSING 493 Priority 1 VERSION 2 Exit Exam - 2021 | Graded A+ (Correct answers highlighted in yellow)$14.99
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Priority 1 VERSION 2 Exit Exam - 2021 | Graded A+
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By: kendrancarlo • 1 year ago
By: tsnurse1929 • 1 year ago
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VERSION 2 - 2021
1. A nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki disease. Which of the following
interventions should the nurse include in the plan of care?
a. Give acetaminophen to control the child’s fever
b. Monitor the client’s cardiac status (PEDS p120)
c. Administer antibiotics via intermittent IV bolus for 24 hrs.
d. Provide stimulation with children of the same age in the play room
2. A nurse observes a client on the psychiatric unit muttering and standing near a window. The client states, “The voices are telling
me to jump.” Which of the following is an appropriate response by the nurse?
a. “Do you recognize the voices as belonging to anyone you know?”
b. “I understand the voices are frightening you, but I do not hear any voices.”
c. “That can’t be true. The only voices in this room are yours and mine.”
d. “You shouldn’t be afraid when you think the voices are telling you to hurt yourself.”
3. A nurse is caring for a client who is preparing his advance directives. Which of the following statements by the client indicates an
understanding of advance directives? (Select all that apply.)
a. “I need an attorney to witness my signature on the advance directives.” *(nurse witnesses it)
b. “I have the right to refuse treatment.” (Leadership p38)
c. “My doctor will need to approve my advance directives.” (just needs to write a prescription)
d. “My health care proxy can make medical decisions for me.” (Leadership p38)
e. “I can’t change my advance directives once submitted.” (yes, you can)
4. A client who is pregnant voices her concern that her 3-year-old son will feel left out once the newborn arrives. Which of the
following statements by the nurse is appropriate?
a. “Offer your son a gift when the baby receives one.” (Provide a gift from the infant to give the sibling)
cc b. “Teach your son to change the baby’s diapers.” (Allow older siblings to help in providing care for the infant)
c. “Tell your son to kiss the baby.” (Maternity p126: Let the sibling be one of the first to see the infant)
d. “Move your son to a toddler bed when the baby arrives. (do this weeks prior to baby’s arrival)
5. A nurse is teaching a client who has nephrotic syndrome about dietary management. Which of the following instructions should
the nurse include in the teaching?
a. Limit total daily sodium intake to 4 to 5 grams
cc B. Obtain most calories from complex carbohydrates (for CKD)
c. Consume a high-protein diet (High protein, high potassium, low sodium)
d. Avoid intake of soy products.
6. A nurse is interviewing an adolescent client who has a history of physical aggression due to anger management issues. Which of
the following is an appropriate question by the nurse?
a. “Did you think about removing yourself from the situation when you became angry?”
b. “Why do you get angry when things don’t go your way?”
c. “How do you think others feel when you express anger?”
D. “What are you thinking about when you express anger?” (assessing the underlying issue of aggression)
7. A nurse is planning care for a client who has a sealed radiation implant and is to remain in the hospital for 1 week. Which of the
following should the nurse include in the plan of care?
a. Wear a dosimeter film badge while in the client’s room. (Med Surg p583)
b. Ensure family members remain at least 3 feet from the client (should be at least 6ft)
c. Limit each of the client’s visitors to 1 hrs. per day. (should be 30 minutes)
d. Remove dirty linens from the room after double bagging.
,8. A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to
take?
a. Sit at or below the client’s eye level during feedings (Funds p215: Observe for aspiration and pocketing of food in the cheeks
or other areas of the mouth)
b. Talk with the client during her feeding
c. Discourage the client from coughing during feedings (encourage pt. to cough to prevent aspiration)
d. Instruct the client to lift her chin when swallowing (tuck chin)
9. A nurse is caring for a preschool child who is dehydrated. Which of the following assessment findings indicates moderate
dehydration?
a. Bradypnea
B. Oliguria (Funds p343)
c. Diaphoresis
d. Excessive tears
10. A nurse is providing teaching to a parent of a child who has varicella. Which of the following statements should the nurse include
in the teaching?
a. “Your child can return to school after a negative titer result.”
b. “Your child can return to school 24 hours after beginning antibiotics.”
c. “Your child can return to school once the lesions have crusted over.” REPEAT 2016
d. “Your child can return to school once the fever has subsided.”
11. A nurse is providing information for a client who has a new prescription for simvastatin. For which of the following should the
nurse instruct the client to monitor and report to the provider?
a. Muscle weakness- rhabdomyolysis
b. Edema
c. Weight loss
d. Fever
12. A nurse on a medical-surgical unit is receiving report on four clients. Which of the following clients should the nurse assess first?
a. A client who is receiving warfarin and has an INR of 3.3
b. A client who had an NG tube inserted 6 hrs. ago and has abdominal distention
c. A client who is 4 hrs. postoperative following a thyroidectomy and reports fullness in the back of the throat (edema
can lead to resp. distress)
d. A client who has acute kidney injury, a creatinine of 4 mg/dL, and a BUN of 52 mg/dL
13. A nurse is receiving report on four postpartum clients. Which of the following clients should the nurse plan to attend to first?
a. A client who reports changing her perineal pad every 2 hrs.
b. A client who reports abdominal pain during breastfeeding
c. A client who has a urine output of 250 mL in 6 hrs.
d. A client who has hyporeflexia while receiving magnesium sulfate REPEAT
14. A nurse is providing nutritional teaching regarding appropriate food choices to a client who has a new diagnosis of uric acid
calculi. Which of the following should the nurse include in the teaching?
a. Roast beef
b. Chicken breast
c. Low-fat yogurt (avoid purine foods [organ meats & shellfish] & poultry)
d. Tuna fish
,15. A nurse in the emergency department is caring for a client who has a full-thickness burn of the thorax and upper torso. After
securing the client’s airway, which of the following is the nurse’s priority intervention?
a. Preventing infection
b. Offering emotional support
c. Providing pain management
d. Initiating IV fluid resuscitation - REPEAT
16. A nurse is caring for a client who will undergo a procedure. The client states she does not want the provider to discuss the results
with her partner. Which of the following is an appropriate response for the nurse to make? REPEAT
a. “The provider will be tactful when talking to your partner.”
b. “You have the right to decide who receives information.”
c. “Is there a reason you don’t want your partner to know about your procedure?”
d. “Your partner can be a great source of support for you at this time.”
17. A nurse is providing teaching about dietary recommendations to the parents of a school-age child who has acute kidney injury.
Which of the following recommendations should the nurse include in the teaching?
a. Provide low-calcium foods
b. Provide high-phosphorus foods
c. Provide low-potassium foods
d. Provide high-sodium foods
18. A nurse is planning care for a school-age child who is 4 hrs. postoperative following perforated appendicitis. Which of the
following actions should the nurse include in the plan of care? REPEAT
a. Apply a warm compress to the operative site every 4 hrs.
b. Offer small amounts of clear liquids 6 hrs. following surgery
c. Give cromolyn nebulized solution every 8 hrs.
d. Administer analgesics on a scheduled basis for the first 24 hrs.
19. A nurse is assessing a client who is 8 hrs. postpartum and has been unable to void. Which of the following actions should the
nurse take first?
a. Pour warm water over the client’s perineum
b. Offer the client a Sitz-bath
c. Insert a sterile catheter
d. Administer an analgesic
20. A nurse is providing nutritional teaching for an older adult client who has seizure disorder and a new prescription for phenytoin.
Which of the following statements by the nurse is appropriate?
a. “Limit foods that contain folic acid while taking this medication.”
b. “You should expect a change in the color of your stool while taking this medication.”
c. “Increase your intake of vitamin D while taking this medication.” - phenytoin complication (bone pain and weakness)
d. “Plan to take this medication with antacids.”
21. A nurse is assessing a client who sustained fractures to both legs in a motor-vehicle crash. Which of the following findings
indicates the client is experiencing a fat embolism?
a. Petechiae on the chest and abdomen ! practice test 2016 A
b. Decreased pedal pulses
c. Pain unrelieved by opioid analgesics
d. Crepitus at the knee joint
22. A nurse is teaching a client who is at 41 weeks of gestation about a nonstress test. Which of the following information should the
nurse include in the teaching?
, a. “You will have a Doppler transducer applied to your abdomen during the test.”
b. “You should massage one of your nipples to stimulate contractions of your uterus.”
c. “You will need blood work before and after the test.”
d. “You should avoid eating or drinking for 4 hrs. before the test.”
23. A home health nurse is assessing a client who has amyotrophic lateral sclerosis (ALS) and has had recent weight loss. Which of
the following is the priority admission data for the nurse to obtain?
a. Changes in appetite
b. Daily fluid intake
c. Swallowing ability - aspirations precautions
d. Prescribed medications
24. A nurse is providing discharge teaching for a client who has myelosuppression following chemotherapy treatment. Which of the
following statements should the nurse include in the teaching?
a. “Eat a diet rich in fresh fruits and vegetables.”
b. “Wear disposable gloves under gardening gloves while working with house plants.”
c. “Children may visit as long as they’ve recently received a live influenza vaccination.”
d. “Check your temperature weekly.”
BONE MARROW SUPPRESSION- IMMUNOCOMPROMISED. AVOID
25. A nurse is caring for a client who has undergone a modified radical mastectomy. The client has a closed-suction drain. Which of
the following actions should the nurse take? REPEAT
a. Maintain the client in supine position for the first 24 hrs.
b. Secure the drain to the bedding
c. Reset the vacuum by compressing the container
d. Position the affected extremity below the level of the client’s heart
26. A nurse is providing discharge instructions to a client who is 1-day postoperative vertical banded gastroplasty for morbid obesity.
Which of the following statements demonstrates an understanding for the dietary teaching?
a. “It should take me 30 to 60 minutes to eat a meal”
b. “I will be limited to pureed foods for the next 6 months.” (weeks)
c. “I should eat three meals per day.”
d. “Vomiting is common and I will have to learn to live with it.”
SERVE TO RESTRICT AND DECREASE FOOD INTAKE HELPS TO PROMOTE WT LOSS
27. A home health nurse is visiting a client whose partner states that she is overwhelmed by caring for him. When suggesting respite
care, which of the following explanations should the nurse provide?
a. “Respite care offers financial resources to help care for your husband.”
b. “Respite care includes volunteers who will perform household tasks.”
c. “Respite care provides clinicians to work with you in caring for your husband.”
d. “Respite care allows for time away from caring for your husband.”
28. A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling urinary catheter. Which of the
following actions should the nurse take during collection?
a. Obtain the urinalysis specimen before the culture specimen.
b. Collect 2 mL or urine for each specimen.
c. Drain the specimen from the drainage bag.
d. Clamp the catheter distal to the injection port.
29. A nurse is caring for four clients. Which of the following clients should the nurse care for first?
a. A client who has hypothyroidism and is stuporous
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