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EXIT EXAM

1. A nurse is caring for a client who has given informed consent for ECT. Just before the procedure, the

client tells the nurse she is considering not going forward with the treatment. Which of the following

statements by the nurse is appropriate?

a. “You don’t have to go through with the treatment.”

b. “Most people who have this procedure feel better following the treatment.”

c. “It’s okay to be nervous before this treatment.”

d. “Your doctor wouldn’t have ordered this treatment unless it was necessary.”

2. While performing a routine assessment, a nurse notices fraying on the electrical cord of a client’s

CPM device. Which of the following actions should the nurse take first?

a. Report the defect to the equipment maintenance staff.

b. Ensure the device inspection sticker is current

c. Remove the device from the room

d. Initiate a requisition for a replacement CPM device

3. A nurse is caring for a client who is postoperative and has a new prescription for hydromorphone.

Which of the following actions should the nurse take?

a. Document administration of the medication upon removal from the medication dispensing

system

b. Withhold the medication if the client does not appear to be in pain.

c. Count the current number of unit doses available in the medication dispensing system

d. Withhold the medication if the client has a fever

4. A nurse performing a change-of-shift assessment. Which of the following clients has the priority

finding?

a. Type 2 DM and a blood glucose of 250 mg/dL

b. Pneumonia with a productive cough and a fever of 38.8° C (101.8° F)

c. 2 hr. post cast placement and has 2+ pitting edema and pallor

d. First-degree heart block and a heart rate of 62/min

5. A nurse in an outpatient mental health facility is providing teaching to a group of adolescents. Which

of the following statements by a client indicates an understanding of the teaching?

a. “I will limit my alcohol use to one drink daily while taking disulfiram.”

b. “I will avoid foods containing tyramine while taking fluoexetine.”

c. “I will take the sustained-release methylphenidate every morning.”

d. “I will take my lithium on an empty stomach.” (pharm pg. 64: taking lithium with food will

help decrease GI distress)

6. A nurse in the emergency department is assessing client who has major depressive disorder. Which

of the following actions should the nurse take first? [View Exhibit]

a. Administer Zofran to the client for nausea

b. Implement seizure precautions for the client

c. Encourage the client to verbalize feelings

d. Obtain the client’s weight

7. A nurse is completing an admission assessment for a client who ahs narcissistic personality disorder.

Which of the following should the nurse expect?

a. Suspicious of others

b. Exhibits separation anxiety

c. Ritualistic behavior

d. Preoccupied with aging

8. Drug Calc: Client weighs 99 lb. Prescribed diet of 1.5 g protein/kg/day. How many grams of protein

per day should the nurse include in the client’s dietary plan?

9. A nurse is planning care for a group of clients and is working with one LPN and one AP. Which of the

following actions should the nurse take first to manage her time effectively?

a. Develop an hourly time frame for tasks

b. Schedule daily activities

c. Determine goals of the day

d. Delegate tasks to the AP

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10. A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium

sulfate via continuous IV infusion. Which of the following actions should the nurse include in the

plan?

a. Restrict the client’s total fluid intake to 250 mL/hr.

b. Measure the client’s urine output every hour

c. Give the client protamine if signs of magnesium sulfate toxicity occur (antidote: calcium

gluconate)

d. Monitor the FHR via Doppler every 30 min

11. A nurse is caring for a group of clients. Which of the following wounds should the nurse expect to

heal by primary intention?

a. Infected laceration

b. Stage II pressure ulcer

c. Approximated surgical incision

d. Partial-thickness burn

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. Client taking clozapine to treat schizophrenia and reports sore throat (pharm pg. 72:

monitor for infection [fever, sore throat, etc.])

b. Client has OCD and is upset about a change in daily routine

c. Client has narcissistic personality disorder and is mocking others during group therapy

d. Client who has 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 noncoring 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 y/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 prior to 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 prior to assessing the FHR

17. A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon

assessment, the nurse notes tidaling in the water seal. Which of the following is an explanation for

the tidaling?

a. There is a loop of tubing below the drainage system

b. The system is working properly (medsurg pg. 104: tidaling in the water seal chamber and

continuous bubbling only in the suction chamber)

c. The lung has re-expanded

d. The tubing is partially obstructed by clots

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EXIT EXAM 1. A nurse is caring for a client who has given informed consent for ECT. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate? a. “You don’t have to go through with the treatment.” b. “Most people who have this procedure feel better following the treatment.” c. “It’s okay to be nervous before this treatment.” d. “Your doctor wouldn’t have ordered this treatment unless it was necessary.” 2. While performing a routine assessment, a nurse notices fraying on the electrical cord of a client’s CPM device. Which of the following actions should the nurse take first? a. Report the defect to the equipment maintenance staff. b. Ensure the device inspection sticker is current c. Remove the device from the room d. Initiate a requisition for a replacement CPM device 3. A nurse is caring for a client who is postoperative and has a new prescription for hydromorphone. Which of the following actions should the nurse take? a. Document administration of the medication upon removal from the medication dispensing system b. Withhold the medication if the client does not appear to be in pain. c. Count the current number of unit doses available in the medication dispensing system d. Withhold the medication if the client has a fever 4. A nurse performing a change-of-shift assessment. Which of the following clients has the priority finding? a. Type 2 DM and a blood glucose of 250 mg/dL b. Pneumonia with a productive cough and a fever of 38.8° C (101.8° F) c. 2 hr. post cast placement and has 2+ pitting edema and pallor d. First-degree heart block and a heart rate of 62/min 5. A nurse in an outpatient mental health facility is providing teaching to a group of adolescents. Which of the following statements by a client indicates an understanding of the teaching? a. “I will limit my alcohol use to one drink daily while taking disulfiram.” b. “I will avoid foods containing tyramine while taking fluoexetine.” c. “I will take the sustained-release methylphenidate every morning.” d. “I will take my lithium on an empty stomach.” (pharm pg. 64: taking lithium with food will help decrease GI distress) 6. A nurse in the emergency department is assessing client who has major depressive disorder. Which of the following actions should the nurse take first? [View Exhibit]