Comprehensive Exam 2|125 Questions with Verified Answers
1. Which type of management style is a case management model for nursing care delivery?
a.
... [Show More] Patient focused and primary nursing.
b. Clinically oriented and business oriented.
c. Centralized and decentralized systems models.
d. Clinical pathways and patient classifications - CORRECT ANSWER A
2. The nurse is assessing a client with multiple trauma from a motorcycle crash who is being ventilated due to multiple organ dysfunction syndrome (MODS). Which system assessment should the nurse monitor as an indicator of MODS progression?
a. Cardiac function.
b. Renal function.
c. Hepatic function.
d. Coagulation system. - CORRECT ANSWER B
3. A staff member tells the charge nurse that a float nurse assigned to work on the unit has made several medication errors in the past, but is currently working with the education department to improve this skill. What action is best for the charge nurse to take?
a. Dismiss the staff nurse's report about the float nurse because it may be just gossip.
b. Call the nursing supervisor and request a different employee be sent to the unit.
c. Assign the float nurse to function as an unlicensed assistive personnel (UAP) for the day.
d. Arrange for someone to be available to assess and assist the float nurse. - CORRECT ANSWER D
4. Parents of a toddler tell the nurse that their child eats little at mealtime, sits at the table with the family only briefly, and wants snacks "all the time." What recommendation should the nurse provide?
a. Give the toddler nutritious snacks.
b. Offer rewards for eating at mealtimes.
c. Avoid snacks so the child is hungry at mealtimes.
d. Explain to the child in a firm manner what is expected. - CORRECT ANSWER A
5. Which action should the nurse implement when implementing a physical assessment of an older client?
a. Avoid unnecessary touching while interacting with the client.
b. Apply additional pressure to palpate the hepatic edge.
c. Arrange the exam sequence to minimizes position changes.
d. Speak loudly and slowly when telling the client how to assist. - CORRECT ANSWER C
6. When culturing a wound, the nurse should obtain the sample from which part of the wound?
a. The outer edges of the wound.
b. All necrotic sections of the wound.
c. Areas containing purulent or pooled exudates.
d. Any particularly painful area of the wound. - CORRECT ANSWER C
7. An adult male with a history of heart failure tells the nurse that his lower extremities and feet swell when he sits at his computer all day. Which response is best for the nurse to provide?
a. Limit the amount of table salt that you add to your meals.
b. Take a daily vitamin with minerals to correct imbalances.
c. Get up and walk around frequently during the day.
d. Elevate your feet every night to reduce swelling. - CORRECT ANSWER C
8. A client is transferred to the postoperative unit after 2 hours in the postanesthesia care unit (PACU). What is the priority nursing action?
a. Determine the client's pain.
b. Take the client's vital signs.
c. Calculate the IV infusion rate.
d. Check the postop prescriptions. - CORRECT ANSWER B
9. The nurse is teaching a client how to self-administer a subcutaneous injection. To help ensure sterility of the procedure, which subject is most important for the nurse to include in the teaching plan?
a. Hand washing prior to preparation of the injection.
b. Method used to aspirate medication from a vial.
c. Selection and rotation of injection sites.
d. Proper disposal of injection equipment. - CORRECT ANSWER B
10. The nurse observes an empty secondary infusion of diltiazem (Cardizem) is attached to the client's IV pump, but realizes that this client has no prescription for Cardizem. In what sequence, from first to last, should the following interventions be implemented? (Place the first action on top and last action on the bottom.)
a. Review medications client is taking.
b. Measure the client's vital signs.
c. Complete an incident report.
d. Notify the healthcare provider. - CORRECT ANSWER B, A, D, C
11. A client with terminal pancreatic cancer is receiving hospice care at home and reports increasing shortness of breath and associated anxiety. Which prescription should the nurse implement first?
a. Prednisone (Deltasone) 10 mg PO.
b. Albuterol (Proventil) 0.5% solution per nebulizer.
c. Morphine sulfate (Roxanol) 5 to 10 mg SL as needed.
d. Oxygen 2 to 6 liters per minute using a nasal cannula. - CORRECT ANSWER C
12. A healthcare provider (HCP) asks the nurse to give a medication to a client, and the nurse tells the HCP that the client is allergic to the medication. The HCP says, "Give the medication or I will report this to your supervisor." What response should the nurse provide?
a. Walk away and ignore the threatening statement.
b. Give the prescribed medication and document the situation.
c. Tell the HCP that both of you should talk to the supervisor now.
d. Respond that this client is not assigned to the nurse. - CORRECT ANSWER C
13. Which action should the nurse take first when performing tracheostomy care?
a. Cleanse around the stoma.
b. Suction the tracheostomy.
c. Oxygenate with 100% oxygen.
d. Secure the new neck strap. - CORRECT ANSWER C
14. Which type of delivery of nursing care is organized around tasks?
a. Team nursing.
b. Primary nursing.
c. Case management.
d. Functional nursing. - CORRECT ANSWER D
15. During an admission assessment interview, a client states, "I do not use many drugs." How should the nurse respond?
a. "Tell me about the drugs you use now."
b. "Explain what you mean by many drugs."
c. "Do you mean legal drugs or illegal ones?"
d. "What kind of drugs are you talking about?" - CORRECT ANSWER A
16. A parent whose 12-year-old child has been inhaling paint fumes asks the nurse, "Can he become addicted to paint fumes?" What is the best response for the nurse to provide?
a. "Only hard drugs like cocaine and heroin can cause problems with addiction."
b. "Tell me what you think may have caused him to start inhaling paint fumes."
c. "Abuse of any of the inhalants can eventually lead to addiction."
d. "Any time you use an illegal substance, you are abusing drugs." - CORRECT ANSWER C
17. What instrument should the nurse use to determine the presence of deep tendon reflexes?
a. Goniometer.
b. Wood's lamp.
c. Reflex hammer.
d. Transilluminator. - CORRECT ANSWER C
18. Which client is at highest risk for chronic kidney disease (CKD) secondary to diabetes mellitus (DM)?
a. Type 1 DM and a serum hemoglobin-A1c of 3.5%.
b. Type 1 DM and retinopathy and mild vision loss.
c. Type 2 DM and hypertension controlled by metoprolol.
d. Type 2 DM and a history of morbid obesity for 5 years. - CORRECT ANSWER B
19. A high school senior is complaining of a persistent cough and admits to smoking 10 to 15 cigarettes daily for the past year. He is convinced that he is hopelessly addicted to tobacco since he tried unsuccessfully to quit smoking last week. Which intervention is best for the nurse to implement?
a. Encourage the student to associate with non-smokers only while attempting to stop smoking.
b. Tell the student that he is still young and should continue to try various smoking cessation methods.
c. Describe cigarette smoking as a habit that requires a strong will to overcome its addictiveness.
d. Provide the student with the latest research data describing the long-term effects of tobacco use. - CORRECT ANSWER A
20. The registered nurse (RN) and practical nurse (PN) are working together to care for a group of clients. Which situation requires intervention by the RN?
a. A client receiving Lactated Ringer's solution requests pain medication.
b. A client with a history of falls needs assistance to the bathroom.
c. A client's indwelling urinary catheter requires manual irrigation.
d. A client with an epidural infusion reports lower extremity parasthesia. - CORRECT ANSWER D
21. An overweight adolescent girl has been to the school nurse three times in the last two months complaining of vaginal and urinary tract infections. What action should the nurse take first?
a. Counsel the girl regarding hygiene.
b. Ask if she is going to the bathroom frequently.
c. Teach the girl the importance of practicing safe sex.
d. Encourage the girl to see the school counselor. - CORRECT ANSWER B
22. A 6-year-old boy says he does not like the food at the hospital. A review of the child's intake reveals that he has eaten very little for the past 2 days. The nurse formulates a nursing problem of, "Imbalanced nutrition, less than body requirements." What action should the nurse implement?
a. Select nutritious foods on the menu for the child.
b. Provide the child with any snack foods between meals.
c. Encourage family members to bring foods from home.
d. Arrange the child's meal tray with generous portions of food. - CORRECT ANSWER C
23. After the sudden death of a severely injured client while in transport by helicopter, the flight nurse discovers that the oxygen tank that was attached to the oxygen supply was empty during the transport. What action should the flight nurse take?
a. Replace the empty tank without reporting the situation to any members of the agency.
b. Complete an adverse occurrence report and submit it to the nurse-manager.
c. Send an anonymous letter explaining the situation to the family of the client.
d. Advise the flight crew of the situation, then suggest that no further discussion be held. - CORRECT ANSWER B
24. Which outcome statement or goal should the nurse include in the plan of care of an adolescent diagnosed with anorexia nervosa?
a. Improve the client's body perception.
b. Consume at least 50% of all meals.
c. Exercise no more than one hour daily.
d. 5% decrease in serum potassium levels. - CORRECT ANSWER B
25. Which clinical finding should the nurse identify in a client who is admitted with cardiac cirrhosis?
a. Jaundice.
b. Vomiting.
c. Peripheral edema.
d. Left upper quadrant pain. - CORRECT ANSWER C
26. While assessing the hair and scalp of an adult client, the nurse notes that the client has dry, brittle hair. Which information should the nurse obtain first?
a. Unexplained weight gain.
b. Current hair care practices.
c. Family history of alopecia.
d. Absence of axillary hair. - CORRECT ANSWER B
27. The nurse obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the nurse implement first?
a. Use an electronic sphygmomanometer to take the BP every 30 minutes.
b. Retake the blood pressure in the same arm, deflating the cuff slowly.
c. Ask another nurse to recheck the blood pressure to compare results.
d. Obtain another blood pressure cuff and retake the blood pressure. - CORRECT ANSWER B
28. Which outcome is best for the nurse to include in the plan of care for a client with impaired social interaction and obsessive-compulsive disorder?
a. Describes success in dismissing persistent thoughts that used be bothersome.
b. Reports that the obsessions and compulsions experienced are silly.
c. Avoids obsessive verbalizations while interacting with family and staff.
d. Participates in one social or recreational activity each morning and afternoon. - CORRECT ANSWER D
29. Which biological practices are federally regulated for healthcare workers? (Select all that apply.)
a. Standard precautions.
b. N-95 tuberculosis standard.
c. Blood-borne pathogen standard.
d. Biological product exposure limit (BPEL).
e. Resource Conservation and Recovery Act (RCRA).
f. As Low as Reasonably Allowable standard (ALARA). - CORRECT ANSWER A, B, C
30. The nurse is planning to withdraw 10 ml of urine from the port on the tubing of a client's indwelling catheter to obtain a urine specimen. In which order should the nurse implement these actions? (Arrange from first on top to last on the bottom.)
a. Clamp the drainage tubing.
b. Place in a biohazard bag.
c. Document the procedure.
d. Label the urine specimen. - CORRECT ANSWER A, D, B, C
31. An elderly client is admitted with suspected bacterial pneumonia and lethargy. Ten minutes after the nurse initiates low-flow oxygen per nasal cannula and a peripheral IV with a secondary infusion of ticarcillin (Ticar), the client becomes disoriented, restless, and tachypneic. Which nursing action has the highest priority?
a. Call for the emergency resuscitation team and retrieve the unit's crash cart.
b. Stop the IV piggyback infusion and increase the oxygen flow to 3 L/minute.
c. Observe the client's trunk and back for any hives and ask about the onset of urticaria.
d. Notify the healthcare provider and prepare to administer IV diphenhydramine (Benadryl). - CORRECT ANSWER B
32. About mid-morning, a 10-year-old child reports to the school nurse complaining of nausea, dizziness, and chills. Further assessment reveals that this child is sweating profusely and has a blood glucose level of 57 mg/dl. Based on these assessment findings, which food is best for the nurse to encourage the child to eat?
a. A chocolate bar.
b. A soft drink.
c. Peanut butter crackers.
d. A piece of buble gum. - CORRECT ANSWER C
33. The nurse is assigned a client with numerous treatments and decides it is not possible to complete all the needed treatments in the time scheduled for this shift. Which process should the nurse use?
a. Delegate tasks to competent team members.
b. Prioritize tasks with the most crucial needs first.
c. Report the incomplete treatments to next shift nurse.
d. Start with the easiest treatment first. - CORRECT ANSWER B
34. A nurse who adheres to the belief that life is sacred should be able to establish a therapeutic relationship most effectively with which client?
a. A terminally ill and depressed client with cancer.
b. A client who is planning to have an elective abortion.
c. A suicidal client who has made a highly-lethal attempt.
d. A client who refuses a blood transfusion due to religious beliefs. - CORRECT ANSWER A
35. A client with aortic valve stenosis develops heart failure (HF). Which pathophysiological finding occurs in the myocardial cells as a result of the increased cardiac workload?
a. Increase in size.
b. Decrease in length.
c. Increase in number.
d. Decrease in excitability. - CORRECT ANSWER A
36. The charge nurse working on a surgical unit must discharge as many clients as possible to prepare for emergency admissions. Which client is stable enough to be discharged from the unit?
a. An older client with end-stage cirrhosis who had a liver biopsy 4 hours ago.
b. A client scheduled for a femoro-popliteal bypass surgery tomorrow.
c. A middle-aged client with acute pancreatitis and lower left quadrant pain.
d. A female client with angina and ectopy noted on the telemetry monitor. - CORRECT ANSWER B
37. A child weighing 44 pounds is receiving a bolus of Ringer's Lactate solution for fluid replacement at 20 ml/kg. How many ml should the nurse administer? (Enter numeric value only.) - CORRECT ANSWER 400
38. The nurse calculates the mean arterial pressure (MAP) for a client whose blood pressure is 152/90. What is the MAP in mm Hg? (Enter numeric value only. If rounding is required, round to the nearest whole number.) - CORRECT ANSWER 111
39. A 60-year-old homeless man who complains of a cough, late-afternoon fever, and night sweats has a 10 mm induration after receiving a purified protein derivative (PPD) skin test. Which action should the nurse implement?
a. Refer for further diagnostic evaluation.
b. Determine exposure of others to the tuberculosis.
c. Begin anti-tubercular drug therapy.
d. Quarantine or isolate to control communicability. - CORRECT ANSWER A
40. During a home visit, the nurse notes that a female client with degenerative joint disease is taking 3 grams of aspirin PO daily. The client complains of tinnitus, and seems confused. Which intervention should the nurse implement?
a. Prepare a written schedule to remind the client when to take each dose of aspirin.
b. Observe the client place each dose in the correct boxes of her pill container.
c. Contact the client's healthcare provider to report the assessment findings.
d. Ask a family member to ensure that the client takes the medication as prescribed. - CORRECT ANSWER C
41. A client is receiving an intramuscular injection at the ventrogluteal site. At what angle should the nurse insert the needle? (Enter numeric value only.) - CORRECT ANSWER 90
42. Which client data is most important for the nurse to obtain prior to beginning a client's blood transfusion of packed red blood cells?
a. Skin turgor.
b. Weight.
c. Oxygen saturation.
d. Vital signs. - CORRECT ANSWER D
43. The cardiac monitor of a 50-year-old client admitted for cocaine ingestion shows ventricular tachycardia (VT) converting to ventricular fibrillation (VF). What priority action should the nurse implement?
a. Prepare for intubation.
b. Defibrillate at 200 joules.
c. Insert intravenous catheter.
d. Obtain arterial blood gases. - CORRECT ANSWER B
44. When making a home visit to a family with a teething 4-month-old, what information is most important for the nurse to provide the parents?
a. Though child development is characterized by individual differences, first teeth usually erupt during the seventh month.
b. Providing cooled teething toys can help decrease the discomfort associated with tooth eruption.
c. No action is required for the common symptoms associated with teething, which include drooling, irritability, and poor sleeping.
d. A slight fever is often associated with teething, but a fever lasting more than three days requires medical attention. - CORRECT ANSWER D
45. When examining the wound of a client who had abdominal surgery yesterday, the nurse finds that the wound edges are close together, there is no sign of redness, and there is a slight amount of bright red blood oozing from the incision. What action should the nurse take?
a. Record these findings in the client's record.
b. Observe closely for possible dehiscence.
c. Notify the healthcare provider that the client's wound is producing a sanguineous drainage.
d. Increase the IV fluid rate and encourage the client to eat more ice chips. - CORRECT ANSWER A
46. When assessing an intravenous (IV) solution infusing by gravity, the nurse observes that the IV fluid continues to flow when pressure is applied above the catheter tip. What action should the nurse implement?
a. Lower the extremity below the level of the client's heart.
b. Gather the supplies needed to discontinue the IV fluid.
c. Obtain an intravenous infusion pump to regulate the rate of infusion.
d. Convert the IV to a saline lock until the healthcare provider is notified. - CORRECT ANSWER B
47. An older adult client begins wearing binaural hearing aids due to presbycusis. Which instruction should the nurse provide to assist the client in adapting to the new hearing aids?
a. Begin wearing the aids in quiet environments to experiment with adjustments.
b. Wear the hearing aids for an hour a day at first, gradually increasing the time.
c. Keep the volume on low until the conditions with noises are audible.
d. Use one hearing aid until comfortable, then add the second aid. - CORRECT ANSWER A
48. When preparing to insert an indwelling urinary catheter, the nurse applies sterile gloves and then tests the catheter balloon for patency. What action should the nurse implement next?
a. Place a sterile drape under the client's buttocks.
b. Instruct the client to inhale and then exhale slowly.
c. Discard the gloves and apply new sterile gloves.
d. Apply a sterile lubricant to the end of the catheter. - CORRECT ANSWER D
49. A client with severe depression tells the nurse, "I do not know why you bother with me or give me pills. I am never going to get well." What is the most therapeutic response?
a. "You need to stop thinking negative thoughts. They get in the way of your recovery."
b. "You are no bother to me or to the staff. We want you to get well and not feel sad anymore."
c. "I have known many clients with depression who have felt better after several weeks of treatment."
d. "You are feeling very pessimistic, but that is part of your illness. It should go away as you recover." - CORRECT ANSWER C
50. A mother calls the emergency department because her 9-year-old son has just fallen on his face and one of his front teeth has fallen out. Which instructions should the nurse provide to preserve the tooth's viability?
a. Clean the tooth with toothpaste.
b. Place the tooth in milk or water.
c. Put the tooth back in the child's mouth.
d. Gently place the tooth in a plastic bag. - CORRECT ANSWER B
51. A male client, who has a 3-year history of Type 2 diabetes that is controlled by diet, is being discharged postmyocardial infarction with a prescription of nitroglycerin tablets for chest pain and regular insulin for treatment of his diabetes. Following teaching, the client tells the nurse that he will make sure he keeps his nitroglycerin bottle in his pants pocket at all times, that he eats and drinks a snack before going to bed, and that he checks his blood glucose before eating in the morning. This client requires further teaching on which subject?
a. Storing nitroglycerin.
b. Fluid intake.
c. Blood glucose monitoring.
d. Diabetic diet. - CORRECT ANSWER A
52. A client who had a cesarean section two weeks ago is admitted to the hospital for an infected surgical abdominal wound. Which room is best for the nurse to assign this client?
a. A negative pressure room.
b. A semi-private room on a surgical unit.
c. A postpartum room in the birthing center.
d. A private room on a medical unit. - CORRECT ANSWER D
53. A nurse is caring for a male client with paranoid schizophrenia who believes that his antipsychotic medications are poison. Which intervention is best for the nurse to implement?
a. Describe the need for consistently taking medications.
b. Offer the medication in a concentrated form.
c. Discard the medication and document the client's refusal.
d. Approach the client with the medication 30 minutes later. - CORRECT ANSWER D
54. A male client who is two days postoperative for a bowel resection moves as little as possible and does not use the incentive spirometer unless specifically reminded. The client reports his pain level at an 8 on a 10-point scale, but refuses a PRN dose of an opioid analgesic and tells the nurse that he can "tough it out." What response is best for the nurse to provide?
a. Side effects are not a concern because they usually decrease over time.
b. Very few clients become addicted to opioids when using them for pain control.
c. There are multiple options of medications that can be offered if one drug does not relieve the pain.
d. Unrelieved pain impairs respiratory and gastrointestinal function and can impair recovery from surgery. - CORRECT ANSWER D
55. A graduate nurse (GN) tells the RN preceptor, "I need to insert a nasogastric tube, and though I was checked off on this procedure in my nursing school's simulation lab, I have never inserted one on a real person." How should the preceptor respond?
a. "I must see documentation of successful check-off by your school's instructor."
b. "Performing the procedure on a simulator is different from performing it on a real person."
c. "Let's review the procedure, then I will supervise you while you perform the procedure."
d. "I will help you, but we need to inform the client that you are new at doing this." - CORRECT ANSWER C
56. A client is receiving a continuous IV infusion and intermittent IV antibiotics. The nurse should plan to collaborate with the case manager regarding which aspect of this client's care? [Show Less]