CJE PRACTICE EXAM 1
A nurse is teaching a group of middle-aged men about stroke prevention. Which statement by a
client requires further teaching?
1
"I will start an exercise program to lose weight."
2
"I have to stop my daily trip to the donut shop for breakfast".
3
"I will decrease my consumption of beer to only one per day."
4
"I will continue smoking but decrease the number of cigarettes." - ANS-"I will continue smoking
but decrease the number of cigarettes."
Correct - Smoking cessation can lower the risk for stroke
Review the chart below. After completing the admission assessment, which prescription does
the nurse identify as a priority?
1
Oxygen
2
NG tube
3
Morphine
4
Normal saline - ANS-Oxygen - Indicated to improve oxygen saturation
NG tube - Required to decompress abdomen, which helps to relieve pain
Morphine - Correct - Pain control is a priority to prevent hemodynamic instability
Normal saline - Indicated to prevent fluid volume deficit because client will be NPO
The charge nurse is observing a newly hired nurse on the medical-surgical unit. Which client
situation should the nurse address first to demonstrate the ability to safely prioritize care?
1
Attempt to calm a patient with anxiety before inserting a Foley catheter.
2
Administer medication for nausea before assessing a client who is complaining of chest pain.
3
Assess a client who reports severe pain before administering routine medications.
4
,Reassess a client who had a seizure an hour ago before assessing a client who has a change
in level of consciousness. - ANS-Assess a client who reports severe pain before administering
routine medications.
The nurse cares for a client 12 hours following a thoracotomy who has a chest tube connected
to a drainage system. The nurse notices that fluid is not draining through the chest tube, but the
tubing is not kinked or occluded in any way. What is an appropriate action by the nurse?
1
Strip the chest tube.
2
Notify the Rapid Response Team.
3
Continue to monitor.
4
Assess for bubbling in the water-seal chamber. - ANS-Notify the Rapid Response Team.
Strip the chest tube. Avoid stripping the chest tube because of the risk for damage to lung tissue
Notify the Rapid Response Team. Correct - Health care provider or Rapid Response Team
should be notified if drainage in tube stops in the first 24 hours.
Continue to monitor. Chest tube should drain less than 100 ml within the first 24 hours
Assess for bubbling in the water-seal chamber. Bubbling in the water-seal chamber is normal.
However, excessive or no bubbling in the water-seal chamber indicates a problem with the
chest tube.
The nurse cares for four clients prescribed atorvastatin Which client requires further evaluation
before delivery of the medication?
1
An older adult female who reports muscle pain with previous doses.
2
An older adult male client who reports experiencing a lot of constipation.
3
A young adult male client with a history of type 1 diabetes.
4
A young adult female who plans to become pregnant this year. - ANS-A young adult female who
plans to become pregnant this year.
A young adult female who plans to become pregnant this year. - Correct - This medication is
contraindicated with pregnancy so the nurse needs to investigate further as if the client is not
taking measure to prevent pregnancy then the client should not be taking atorvastatin.
The nurse completes medication reconciliation with an older adult client admitted with
Parkinson's disease? Which medication should the nurse question?
Docusate (Colace) - This is given to prevent constipation and can be used with older adult
clients as it is a stool softener and not a laxative.
Benztropine- Correct - This should be avoided in older adults because it can cause acute
confusion, urinary retention, constipation, dry mouth and blurred vision.
Amantadine (Symmetrel) - The client is prescribed this medication along with
levodopa-carbidopa to help reduce symptoms of the condition.
Levodopa-carbidopa (Sinemet) - This is the initial drug of choice for use in Parkinson's disease.
It may need to be removed from the regimen later in the disease process, but there is no
indication in the question that the client is ready for this.
The nurse has instructed an unlicensed assistive personnel (UAP) how to care for a client with
skeletal traction. Which action by the UAP indicates a need for further teaching?
1
Elevates head of bed before the client eats.
2
Places the weights on bed before repositioning.
3
Records urine output after emptying Foley catheter.
4
Wipes foot with a wet towel where traction is located. - ANS-Places the weights on bed before
repositioning.
Elevates head of bed before the client eats. This is a correct action to prevent aspiration
Places the weights on bed before repositioning. Correct - This is a wrong action by the UAP.
Weights should be kept hanging at all times.
Records urine output after emptying Foley catheter. This is a correct action
Wipes foot with a wet towel where traction is located. This is permitted to promote skin integrity
The nurse is assessing a client in the emergency department who was involved in a motor
vehicle accident. Assessment findings include periorbital ecchymosis, bruising behind the ears,
and leakage of clear fluid from the nose. What is an appropriate action by the nurse?
1
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