RN Comprehensive Predictor Version 2 150 Verified Q&A (Complete)
1. The nurse shows a teenager how to use a metered dose inhaler of ipratropium
... [Show More] (Atrovent). Which statement, if made by the client to the nurse, indicates teaching is effective?
1. “I should use this medicine to stop the coughing that leads to an asthma attack”
2. “I should use this medicine if I begin to have an asthma attack”
3. “I should use this medicine right after I have an asthma attack”
4. “I should use this medicine to prevent an asthma attack” Answer#2
2. An older client is scheduled for a magnetic resonance imaging MRI procedure. Which of the following statements, if made by the client to the nurse, should be reported to the technician before the test?
1. “I take medication to control my blood pressure”
2. “I have had diabetes for about 10 years now”
3. “I had a knee replacement 5 years ago”
4. “I am allergic to penicillin and sulfa medications”
Answer#3
3. The nurse makes the following observations of a 6 hour old newborn: axillary temperature 96.4 F (35.8 C), apical pulse 148, respirations irregular at 48/minute, black sticky stool, blood glucose 60mg/dL. It is most important for the nurse to take which action?
1. Feed the newborn 30mL of infant formula
2. Administer low flow oxygen to the newborn
3. Wrap the newborn in a warmed blanket
4. Perform a guaiac test on the newborns stool Answer#3
4. A client is returned to the unit at 10AM after laparoscopic gallbladder surgery. The nurse plans to get the patient out of bed for the first time at 4PM. It is MOST important for the nurse to take which of the following actions?
1. Turn the patient from side to side at 2 PM
2. Offer pain medication to the patient at 3:30PM
3. Encourage the patient to use the incentive spirometer at 3PM
4. Cough and deep-breathe the patient at 2:30PM Answer#1
5. The activity therapy staff takes a group of psychiatric patients on a trip to the zoo. The nurse should intervene with which of the following patients before their departure?
1. A 50 year old female who is having difficulty with sleeping, eating, and social interaction.
2. A 40 year old male who just received his third dose of trazodone (Desyrel) and is 20 pounds overweight.
3. A 42 year old female who has problems with decision making who paces
continuously, wringing her hands.
4. A 38 year old female who is receiving chlorpromazine (Thorazine) and is wearing a sundress without a hat or sunglasses.
Answer#4 (photosensitivity;causes sensitivity to sun)
6. A patient experiences skin eruptions due to an allergic reaction to a medication. The nurse demonstrates the BEST documentation with which of the following?
1. “Patient complains of rash and itching over most of his body. Patient is concerned about how it looks”
2. “Multiple red welts noted over trunk and both arms. Patient states that welts itch”
3. “Allergic skin reaction to medication experienced by patient. Started several hours ago”
4. “Vital signs stable. Patient scratching arms and chest area frequently”
Answer#2
7. An older client diagnosed with emphysema is admitted to the psychiatric unit for treatment of bipolar disorder. The client receives oxygen per nasal cannula. The client expresses concern to the nurse that someone will come in and change the amount of oxygen the client is receiving. INITIALLY, the nurse should take which of the following actions?
1. Schedule an in-service with the staff about emphysema
2. Place a sign above the patient’s bed stating that the oxygen level is not to be changed
3. Tell the patient she will be well cared for in the hospital
4. Convey the patient’s concern to the nursing staff
Answer#2
8. A teenager has a positive home pregnancy test and comes to the prenatal clinic. The girl is uncertain of the date of her last menstrual period. The nurse palpates the uterine fundus midway between the symphysis pubis and the umbilicus. Which statement by the nurse is BEST?
1. “You are 24 weeks pregnant. It is good that you came in for prenatal care”
2. “You are 30 weeks pregnant. Prenatal care is important for you and your baby”
3. “You are 16 weeks pregnant. Let’s talk about what that means”
4. “You are 8 weeks pregnant. Are your periods usually irregular?”
Answer#3
9. A client is admitted to the psychiatric unit with complaints of fatigue, inability to concentrate, lack of appetite, and repetitive thoughts. The client is reluctant to take the prescribed medications, fearing that they are harmful. After the nurse gives the client the medication, the nurse should take which of the following actions?
1. Instruct the client to open her mouth and move her tongue up and down and to each side while the nurse looks inside.
2. Ask the client if she has swallowed the medication completely.
3. Watch the client’s behavior to see if the medication is having its desired effect.
4. Observe the clients throat while she swallows several times after putting the medication in her mouth. Answer#1
10. The nurse assesses a patient 72 hours after a total joint replacement of the right hip.
Which finding requires an intervention by the nurse?
1. There is a pillow between the patients legs
2. The patient’s legs are internally rotated
3. The patients hip joint is flexed at a 70 degree angle when the patient sits in the chair
4. The patient has not requested pain medication for 12 hours.
Answer#2 (prevent internal or external rotation, that means se safó)
11. A client newly diagnosed with Meniere’s disease plans a trip to an amusement park with the family. The client asks the clinic nurse which of the following rides is best. The nurse should suggest which of the following rides?
1. Roller coaster
2. Merry go round
3. Ferris wheel
4. Train
Answer#4
12. A client is discharged from the hospital after coronary bypass (CABG) surgery 3 days ago. During discharge teaching, the client asks the nurse “When can I resume sexual intercourse with my wife?” it is best for the nurse to make which of the following statements?
1. “You can resume sexual activity when you feel strong enough”
2. “You can resume sexual activity when you are able to walk one block without chest pain or discomfort”
3. “You may have difficulty maintaining an erection because of your recent surgery”
4. “You should abstain from sexual activity because it may be detrimental to your recovery”
Answer#2 (one block or two flights of stairs without chest pain)
13. A woman complains to the nurse about the care provided to her husband by the nursing staff the previous night. Initially, the nurse should take which of the following actions?
1. Ask the wife to voice her expectations about a solution to the problem
2. Gain consensus with the woman on the specific steps that will be taken care for her husband
3. Explain to the wife that the problems she identified will be fixed
4. Notify the wife that everything possible is being done for her husband
Answer#1
14. A patient is restrained bodily by the nursing team. The hands of the nurse assigned to hold down the patients leg should be placed in which of the following positions?
1. One hand on the patients knee and the other hand on the patients ankle
2. One hand directly above the patient’s knee and the other hand directly above the patient’s ankle
3. Both hands side by side on the patients thighs
4. One hand at the patients groin and the other hand at the patients mid-calf area
Answer#2
15. The nurse in the community mental health center works with a client who is diagnosed with depression. Cognitive therapy is initiated. The nurse should take which of the following actions?
1. Assist the client to review past intellectual achievements
2. Help the client develop more positive thoughts
3. Help the client to identify the source of his depression 4. Change the client’s values and beliefs.
Answer#3
Cognitive Therapy; determined that how individuals feel and behave is determined by how they think about the world and their place in it.
16. The nurse plans to perform a physical assessment of a young adult who has been deaf since birth. Although the client indicates using sign language, no interpreter is available.
The nurse should take which action?
1. Face the client and speak slowly using low-pitched voice
2. Write out each question, and ask the client to write out each answer
3. Sit on the clients right side and use gestures and nonverbal clues
4. Show the client pictures of the parts of the body that will be examined
Answer#2
17. A patient received morphine 4 mg IV 2 hours ago for the complaints of postoperative pain. The patient turns on the call light and tells the nurse he has to go to the bathroom. The patient has bathroom privileges. The nurse should take which of the following actions?
1. Obtain a bedside commode for the patient to use
2. Provide a warmed fracture bedpan for the patient to use
3. Tell the patient to breathe deeply as he walks to the bathroom
4. Ask the patient sit on the side of the bed before proceeding to the bathroom
Answer#4
18. The nurse cares for a patient on the psychiatric unit with a history of drug use and poor impulse control. After the patient’s mother visits, the patient begins pacing rapidly, with arms swinging, and kicking at chair legs. The nurse should approach the patient and take which of the following actions?
1. Sit in a chair several feet away from the patient and lean forward with hands clasped together
2. Stand facing the patient with legs apart, knees locked, and weight on back leg 3. Sit in a chair next to the patient and lean back with arms folded
4. Stand facing the patient, legs together, knees locked, with weight on both legs
Answer#2
19. The nurse observes the nursing assistant giving morning care to an elderly client who has an area of warm, reddened skin on the sacrum that does not blanch with pressure.
Which action by the nursing assistant requires an intervention by the nurse?
1. The aide cleanses and then applies A and D ointment to the reddened area
2. The aide firmly massages the reddened area in a circular motion
3. The aide placed a piece of sheepskin under the patients sacrum
4. The aide positions the patient on the left side with head of the bed flat Answer#2 (Stage I pressure ulcer, do not massage can damage capillary beds and cause tissue necrosis)
20. The school nurse identifies several children who have food allergies. Which sequence should the nurse teach the staff to follow if an allergic reaction is observed in a child?
1. Call 911, call the physician, administer EpiPen, call the parents
2. Administer the EpiPen, call 911, call the physician, call the parents 3. Call the physician, administer the EpiPen, call 911, call the parents
4. Call the parents, administer the EpiPen, call the physician
Answer#2
21. A client comes to the ER complaining of shortness of breath, fatigue, insomnia, and weight loss. The client states that the client’s company forced the client into early retirement. The client says that the client has been sick ever since the client stopped working. The nurse should take which of the following actions first?
1. Encourage the patient to find outlets for his job skills in a consultative or volunteer basis in the community
2. Help the client see a connection between his symptoms and emotions, while investigating each symptom
3. Tell the client that anger is an unacceptable reason to something being taken away
4. Explain to the client what retirement should be like, and contrast this with what he has experienced Answer#2
22. The nurse teaches the woman diagnosed with type 1 diabetes who is pregnant for the first time. The nurse teaches the client that as the pregnancy advances, the client may require which implementation?
1. Decreased amounts of insulin
2. Increased amounts of insulin
3. Decreased amounts of carbohydrates in her diet
4. Increased amounts of protein in her diet
Answer#2
23. The nurse cares for a patient after a colon resection. The patient has a Salem sump tube connected to intermittent suction. The patient asks the nurse, “When will I be able to eat?” Which is the BEST response by the nurse?
1. “You will be given a high-calorie, high-fiber diet in a few days”
2. “You will be started on clear liquids when we hear your stomach make noises”
3.”You can eat food when the NG tube is removed in about 5 to 6 days”
4. A soft diet will be given to you after you have your first bowel movement”
Answer#2
24. The nurse supervises care provided for a client immediately after cardioversion. Which observation, if made by the nurse, indicates the need for an intervention?
1. A cold cloth has been applied to the paddle sites on the patient’s chest
2. The patient’s dentures remain in a cup at the bedside
3. There is an NPO sign above the patients bed
4. The oxygen the patient was receiving before the procedure remains disconnected
Answer#4
25. The nurse cares for a client diagnosed with bursitis of the right shoulder. The nurse expects the client to experience which of the following?
1. Pain and numbness in the first two fingers and thumb of her right hand
2. Spasms of the right hand when a blood pressure cuff is initiated and left in place for
2 minutes
3. A constant dull ache originating in the neck and radiating down the right arm
4. Pain with extension, flexion, and internal rotation of the right arm
Answer#4
26. The nurse supervises care provided by the nursing assistive personnel (NAP) to the older client in the convalescent phase after a stroke. The nurse should intervene if which action is observed?
1. The client is supine with a pillow under the head
2. The client is positioned laterally on the left side with the head of the bed flat
3. The client sits with the head of the bed elevated and the knee gatch up
4. The client is positioned laterally on the right side with the head of the bed flat
Answer#1
(Brain attack or CVA; keep head unaffected side, no neck flexion or extension, head of bed flat)
27. The nurse cares for a client who is receiving amitriptyline (Elavil) 25 mg q A.M. and 100 mg at HS. The nurse understands that the medication schedule will accomplish which of the following?
1. Make therapeutic use of an expected side effect of the medication
2. Decrease interference between digestion of food and absorption of medication
3. Utilize the increased permeability of the blood-brain barrier that occurs during sleep 4. Reduce the side effects experienced by the client
Answer#4
(Antidepressant, tryciclic; it has a sedative effect, administer larger dose at night it causes increased sedation)
28. An older patient falls on the floor of the psychiatric unit. To determine the cause of the fall, it is MOST important for the nurse to do which of the following?
1. Check the patients eyeglasses
2. Examine the condition of the patients shoes
3. Monitor the patients’ blood pressure
4. Evaluate the floor where the patient fell
Answer#4
29. The nurse instructs a prenatal class for first-time mothers. A group of mothers state they are afraid because they have heard that babies often die in their sleep before their first birthday. The mothers ask what they can do to prevent this. It is BEST for the nurse to make which of the following responses?
1. it’s important for you to focus on your pregnancy and upcoming labor and not to focus on negative things that may happen in the future
2. This does not happen very often. With good nutrition and loving care your babies should thrive and develop normally
3. Unfortunately, the cause of this condition is not definitely known, so there is little you can do to prevent this from happening
4. It’s best to position the baby on its back or side in bed. There seems to be an increase in this condition when babies are put to sleep on their stomach Answer#4
30. A client attends a support group for incest survivors at the community mental health center. The client tells the nurse, “I don’t get it. People keep telling me I talk just like my father. He’s the last person I’d want to act like!” which response by the nurse is BEST?
1. Genetically, you are like your father
2. You need to be more open-minded. I’m sure your father had some good qualities
3. Don’t worry about what everyone else is saying
4. Sometimes people unconsciously take on the characteristics of people who exert power over them
Answer#4 To exert is to apply or use. Waleska=mami
31. The family of a patient admitted to the psychiatric unit 3 days ago arrives for a visit carrying two suitcases. The nurse informs the family that before they can proceed into the unit, the suitcases need to be searched. The family asks why this needs to be done. Which is the BEST response by the nurse?
1. “We know what is best for our patients”
2. “We have to make sure you’re not bringing contraband”
3. “Were just following the rules established by administration”
4. “Things that you may not think of as being harmful may be used for harm by the patient
Answer#4
32. The nurse asks the nursing assistant to obtain morning vital signs on several patients. It is best for the nurse to make which of the following statements?
1. “Go check the vital signs for the patient in rooms 321 and 322. Record your findings on this sheet and then return it to me”
2. “Today you’ll check patient’s vitals. Please start with rooms 321 and 322. Be sure to
write them down”
3. “Since you have been taught to check vital signs for patients, you can take them on patients in rooms 321 and 322. Let me know your findings”
4. “The patients in room 321 and 322 need to have their morning vital signs taken. This allows us to compare the results to what the night nurse documented.” Answer#1
33. The nurse reviews basic communication skills with a new group of nursing assistants. It is BEST for the nurse to make which of the following statements?
1. “Understanding nonverbal behavior assures success in interpersonal relationships
2. “Nonverbal behavior is best considered in combination with verbal communication”
3. “There is no specific meaning for each type of nonverbal behavior”
4. “Altering nonverbal behavior is a form of manipulation”
Answer#2
34. The nurse cares for a woman at 7 months gestation diagnosed with preeclampsia. The client comes to the outpatient clinic for her weekly checkup. The nurse is MOST concerned if which of the following is observed?
1. The clients temperature is 98.2 F (36.7 C)
2. The client has 2+ pitting edema of her feet
3. The client gained 1 pound since the last visit
4. The client’s skin is dry
Answer#2
35. A client with a history of arterial insufficiency is seen in the outpatient clinic. The client complains to the nurse about frequent awakenings during the night because of a burning numbness in the lower extremities. The nurse should advise the client to take which of the following actions?
1. Elevate the legs on several pillows
2. Get up and walk around the room
3. Place the legs in a dependent position
4. Perform leg exercises
Answer#3 (Elevate veins; dangle arteries)
36. A 31-year-old female undergoes a tubal ligation. When the patient regains consciousness, the nurse elevates the head of the bed 60 degrees. The patient says to the nurse, “I feel dizzy.” The nurse should take which of the following actions?
1. Lower the head of the bed slowly
2. Tell the patient the dizziness will go away soon
3. Turn the patient onto her left side
4. Elevate the foot of the bed
Answer#1
37. The nurse completes the preoperative checklist for an elderly woman before a vaginal hysterectomy. Which assessment would require an intervention by the nurse before the patient can go to the operating room?
1. The patient’s partial dentures are in a denture cup at the bedside
2. A religious medal is pinned to the patients hospital gown
3. The patients long hair is pulled back using hairpins
4. The patient’s wedding ring is taped in place
Answer#4
38. The nurse suspects that a patient has autonomic dysreflexia (hyperreflexia). Which symptom supports the nurse’s conclusion?
1. The nurse documents that the patients pulse has changed from 82 to 98
2. The patients’ blood pressure changes from 120/80 to 150/96
3. The nurse finds that the patents reflexes are hyperactive
4. The nurse noted that the patient is becoming drowsy
Answer#2
(Paroxysmal HTN, bradycardia, excessive sweating, facial flushing, nasal congestion, pilomotor responses, and headache, to bring blood pressure down, sit patient upright).
39. A newborn’s birth weight is above the 95th percentile for estimated gestational age of 39 weeks. Which term should the nurse use for documentation about this infant?
1. Post-term, LGA
2. Term, LGA
3. Preterm, SGA
4. Term, AGA
Answer#2
40. The nurse completes an incident report after a complaint about nursing care from the family of a patient. Which is the BEST statement for the nurse to make?
1. “Patients daughter complained about the poor nursing care delivered to father on
6/2 and 6/3. Staff meeting held. Will check on patient more often during the night.”
2. “Patients daughter unsatisfied with care given to father on room 322, bed A on 6/2 and 6/3. No evidence of poor care or injury to patient. Plan of care for patient revised”
3. “Patients daughter stated that she found her father lying in bed wet with urine when she arrived on 0730 on 6/2 and 6/3. Skin intact on patients back, buttocks, and perineal areas. Discussed situation with nursing staff”
4. “Patients daughter voiced concern about the care provided to father by the staff on 6/2 and 6/3. Assured daughter that every effort will be made to make sure his needs are met” Answer#3
41. The nurse plans care for a patient with catatonic schizophrenia admitted to the inpatient psychiatric unit. Which is the best goal for the nurse to establish for this patient INITIALLY?
1. The patient will report to the nurse to obtain the prescribed medications
2. The patient will select the clothes to wear everyday
3. The patient will attend group meetings in the unit
4. The patient will eat at mealtime with help from the nursing assistant
Answer#4
Assess client’s physical needs FIRST, MASLOW.
42. At the bedside of a patient, the nurse is preparing for insertion of a percutaneous intravenous catheter (PICC) line. The patient holds out the left arm and says, “Please put it in this arm; I’m right handed.” Which response by the nurse is best?
1. The placement of the line won’t affect the use of your hand. The line is always placed on the left side, near the heart
2. The line needs to go into your right arm. It is important for you to move your arm while the line is in place
3. That is helpful to know. We will put the line in your left arm as you wish
4. The line won’t go into either of your arms. The line will go through a spot under your collarbone Answer#4 [Show Less]