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Nursing Comprehensive Exam 3

50 Questions
Nursing Quizzes & Trivia
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  • 1. 
    A client’s vital signs have noticeably deteriorated over the past four hours following surgery.  A nurse does not recognize the significance of these changes in vital signs and keep no action.  The client later requires emergency surgery.  The nurse could be prosecuted for inaction according to the definition of which of these?
    • A. 

      Tort

    • B. 

      Misdemeanor

    • C. 

      Common law

    • D. 

      Statutory law

  • 2. 
    A nurse calls the physician of a client scheduled for a cardiac catherization because the client has numerous questions regarding the procedures and has requested to speak to the physician.  The physician is very much upset and arrives at the unit to visit the client after prompting by the nurse.  The nurse is outside of the client’s room and hears the physician tell the client in derogatory manner that the nurse “doesn’t know everything”.  Which legal tort has the physician violated?     
    • A. 

      Libel

    • B. 

      Slander

    • C. 

      Assault

    • D. 

      Negligence

  • 3. 
    A nurse enters a client’s room and finds the client sitting on the floor.  The nurse performs a thorough assessment and assists the client back to bed.  The nurse completes an incident report and notifies the physician of the incident.  Which of the following is the next appropriate nursing action regarding the incident?           
    • A. 

      Make a copy of the incident report for the physician

    • B. 

      Place the incident report on the client’s chart

    • C. 

      Document a complete entry in the client’s record concerning the incident

    • D. 

      Document in the client’s record that an incident report has been completed

  • 4. 
    A client had a colon resection. A Levin tube is placed when a regular diet was brought to the client’s room. The client didn’t want to eat the solid food and ask the physician to be called.  The nurse insisted that the solid food was the correct diet.  The client ate and subsequently had additional surgery because of complications.  The determination of negligence is based on:
    • A. 

      A duty existed and it was breached

    • B. 

      Not calling the physician

    • C. 

      The dietary department sending the wrong food

    • D. 

      The nurse’s persistence

  • 5. 
    A new nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the facility.  The nurse is told that the nursing model is the primary nursing approach.  The nurse understands which of the following is a characteristic of this type of nursing model of practice?             
    • A. 

      The nurse manager assigns tasks to the staff members

    • B. 

      Critical paths are used in providing client care

    • C. 

      A single registered nurse (RN) is responsible for planning and providing individualized nursing care

    • D. 

      Nursing staff are led by an RN leader in providing care to a group clients.

  • 6. 
    A client asks the nurse how to become an organ donor.  Which of the following would not be a component of the nurse’s response?      
    • A. 

      The donor must be 18 years of age or older

    • B. 

      The donation is done by written consent

    • C. 

      The family is responsible for making that decision at the time of death.

    • D. 

      Clients have the right to donate their own organs for transplantation

  • 7. 
    A registered nurse (RN) is providing instructions to a licensed practical nurse (LPN) who is preparing to care for a deceased client.  The RN notes on the client’s record that his/her eye will be donated.  The nurse avoids telling the LPN to do which of the following?   
    • A. 

      Elevate the head of the bed

    • B. 

      Close the client’s eye

    • C. 

      Place wet saline gauze pads and an ice pack on the eyes

    • D. 

      Close the client’s eyes and place a dry sterile dressing over the eyes

  • 8. 
    A clinical nurse manager is planning an in-service educational session for the staff nurses.  The topic of the discussion is case management.  Which of the following is not a characteristic of case management and would not be included in the discussion?  
    • A. 

      Represents a primary health prevention managed by a single case manager

    • B. 

      Manages the client care by managing the client care environment

    • C. 

      Designed to promote appropriate use of hospital personnel and material resources

    • D. 

      Maximizes hospital revenues while providing for optimal outcome of client care

  • 9. 
    • A. 

      Assist a 12-year old boy who is profoundly developmentally disabled to eat lunch

    • B. 

      Obtain frequent oral temperatures on a client

    • C. 

      Accompany a 51-year-old man, being discharged to home following a bowel resection 8 days ago, to his transportation

    • D. 

      Collect a urine specimen from a 70-year old woman admitted 3 days go

  • 10. 
    • A. 

      A client is performing own colostomy care

    • B. 

      A 1-day postoperative client has a temperature of 98 degrees F

    • C. 

      Purulent drainage is noted from a postoperative wound incision

    • D. 

      A new diabetic client is preparing own insulin for injection

  • 11. 
    • A. 

      Laissez-faire

    • B. 

      Authoritarian

    • C. 

      Situational

    • D. 

      Participative

  • 12. 
    A client with a right pleural effusion noted on a chest x-ray film is being prepared for thoracentesis.  The client experiences severe dizziness when sitting upright.  The nurse assists the client to which of the following positions for the procedure?
    • A. 

      Prone, with the head turned to the side supported by a pillow

    • B. 

      Sims’ position, with the head of the bed flat

    • C. 

      Right side-lying, with the head of bed elevated 45 degrees

    • D. 

      Left side-lying with the head of the bed elevated 45 degrees

  • 13. 
    A physician’s order reads: theophylline timed-release capsule (Slo-bid), 100mg PO every 6 hours.  The medication label reads: 50 mg /capsules.  The nurse prepares how many capsule(s) to administer one dose?
    • A. 

      1

    • B. 

      2

    • C. 

      3

    • D. 

      4

  • 14. 
    A physician has written an order for a vest restraint to be applied on a client from 10:00 PM to 7:00 AM because the client becomes disoriented during the night and is at risk for fall. At 6:30 AM, the nurse manager takes rounds on all the clients in the  unit. When assessing the client with vest restraint, which observation would indicate that the nurse who cared for this client performed unsafe care in the use of the restrain?          
    • A. 

      A hitch knot was used to secure the restrain

    • B. 

      The client’s record indicates that the restraint was released every 2 hours

    • C. 

      The restraint was applied tightly to prevent a fall

    • D. 

      The call light was placed within reach of the client

  • 15. 
    The nurse is providing an educational session to a group of students who are enrolled in a certified nursing assistant program.  The nurse prepares an instructional list for the students regarding the correct procedure for hand washing.  Which instructions does the nurse include on the list?
    • A. 

      Turn on the water. Allow warm water to wet the hands. Apply soap to the hands and rub them vigorously. Keeps hands pointed downward. Rinse the hands. Dry the hands using a paper towel.

    • B. 

      Turn the water faucet off with the paper towel. Turn on the water. Allow the warm water to wet the hands. Apply soap to the hands and rub them vigorously. Keep hands pointed upward. Rinse the hands. Dry the hands using a paper towel. Turn the water faucet off with the paper towel.

    • C. 

      Turn on the water. Allow the warm water to wet the hands. Apply soap to the hands and rub them vigorously. Keep the hands pointed down ward. Rinse the hands using a paper towel. Turn the water off with the clean hands.

    • D. 

      Turn on the water; allow the cold water to wet the hands. Apply soap to the hands and rub it vigorously. Keep hands pointed upward. Rinse the hands using a paper towel and warm water. Turn the water off with clean hands.

  • 16. 
    A nurse is preparing to suction a client through a tracheostomy tube.  Which of the following protective items would the nurse wear to perform this procedure?  
    • A. 

      Gown, mask and sterile gloves

    • B. 

      Goggles, mask and sterile gloves

    • C. 

      Mask, gown and a cap

    • D. 

      Mask, sterile, gloves and a cap

  • 17. 
    A nurse is instructing a client on how to safely use crutches for ambulating at home.  Which measure would the nurse recommend to minimize the risk of falls while ambulating with crutches? 
    • A. 

      Use grab bars in the bath tub or shower

    • B. 

      Remove scatter rugs in the home

    • C. 

      Keep all pets out of the house

    • D. 

      Use soft-soled slippers when walking with the crutches.

  • 18. 
    • A. 

      Walk up behind the client and gently put a hand on the client’s shoulder while speaking

    • B. 

      Speak to the client at the entrance of the room to avoid any episodes of violence

    • C. 

      Speak and move slowly to the client while assessing the client’s needs

    • D. 

      Wait until the client’s agitation has subsided before approaching the client.

  • 19. 
    A nurse has administered an injection to a client.  After the injection, the nurse accidentally drops the syringe on the floor.  Which nursing action is the most appropriate in this situation? 
    • A. 

      Carefully pick-up the syringe from the floor and gently recap the needle

    • B. 

      Carefully pick up the syringe in the floor and dispose it in sharps container

    • C. 

      Obtain a dust pan and mop to sweep up the syringe

    • D. 

      Call the housekeeping department to pick up the syringe

  • 20. 
    A nurse is observing a client using a walker.  The nurse determines that the client is using the walker correctly if the client is:     
    • A. 

      Puts all four points of the walker flat on the floor, puts weight on the hand pieces and then walks into it.

    • B. 

      Put weight on the hand pieces, moves the walker forward and then walks to it

    • C. 

      Puts weight on the hand pieces, slides the walker forward and then walks unto it

    • D. 

      Walks into the walker, puts weight into the hand pieces, and then puts all four points of the walker on the flat floor

  • 21. 
    • A. 

      The client is able to rest axillae on the axillary bars

    • B. 

      The nurse is able to place two fingers comfortably between the axillae and the axillary bars

    • C. 

      The client is able to maintain the arms in a straight position when standing with the crutches

    • D. 

      The nurse is able to place four fingers comfortable between the axillae and axillary bars

  • 22. 
    A client has a risk for infection following radical vulvectomy.  The nurse avoids which of the following when giving perineal care to this client?            
    • A. 

      Cleanses using warm tap water and a bulb syringe

    • B. 

      Intermittently exposes the wound to air.

    • C. 

      Provides perineal care after each voiding and bowel movement (BM)

    • D. 

      Provides prescribed sitz baths after the sutures are removed

  • 23. 
    A nurse prepares to assist a postoperative client to progress from a lying to a sitting position to prepare for ambulation.  Which nursing action is most appropriate to maintain safety of the client? 
    • A. 

      Assist the client to move quickly from the lying position to the sitting position

    • B. 

      Assess the client for signs of dizziness and hypotension

    • C. 

      Elevate the head of the bed quickly to assist the client to a sitting position.

    • D. 

      Allow the client to rise from the bed to standing position unassisted

  • 24. 
    A nurse is inserting an indwelling urinary catheter into a male client.  As the catheter is inserted to the urethra, urine begins to flow into the tubing.  At this point, the nurse:
    • A. 

      Immediately inflates the balloon

    • B. 

      Withdraws the catheter approximately 1 inch and inflates the balloon

    • C. 

      Inserts the catheter until resistance is met and inflates the balloon

    • D. 

      Inserts the catheter 2.5 to 5 cm and inflates the balloon

  • 25. 
    A nurse has just collected a sputum specimen by expectoration for a culture on a  client who has a productive cough.  The nurse plans to implement all of the following interventions.  Which of the following nursing action does the nurse identify as the priority?
    • A. 

      Giving the client mouthwash

    • B. 

      Checking to see that the sputum basin is clean

    • C. 

      Sending the sputum specimen to the laboratory immediately

    • D. 

      Providing tissues for the expectoration

  • 26. 
    A male client who is admitted to the hospital for an unrelated medical problem is diagnosed with urethritis resulting from chlamydial infection.  The nursing assistant assigned to the client asks the nurse what measures are necessary to prevent contraction of the infection during care.  The nurse tells the assistant that:    
    • A. 

      Enteric precautions should be instituted for the client.

    • B. 

      Contact isolation should be initiated, since the disease is highly contagious

    • C. 

      Universal precautions are quite sufficient, since the disease is transmitted sexually

    • D. 

      Gloves and mask should be used when in the clients room.

  • 27. 
    A client is scheduled for gallbladder surgery is mentally impaired and is unable to communicate.  In regard to obtaining permission for the surgical procedure, which nursing intervention would be most appropriate?
    • A. 

      Ensure that the family has signed the informed consent

    • B. 

      Ensure that the client has signed the informed consent

    • C. 

      Inform the family about the advance directive process

    • D. 

      Inform the family about the process of a living will

  • 28. 
    A client diagnosed with tuberculosis (TB) is scheduled to go to the radiology department for a chest x-ray evaluation.  Which nursing intervention would be appropriate when preparing to transport the client?  
    • A. 

      Apply a mask to the client

    • B. 

      Apply a mask and gown to the client

    • C. 

      Apply a mask, gown, and gloves to the client

    • D. 

      Notify the x-ray department so that the personnel can be sure to wear mask when the client arrives.

  • 29. 
    A nurse is taking care of a client on contact isolation.  After the nursing care has been performed, before leaving the room, which protective item worn during client care would the nurse remove first?
    • A. 

      Gloves

    • B. 

      Mask

    • C. 

      Eye wear (goggles)

    • D. 

      Gown

  • 30. 
    A client requests pain medication and the nurse administers an intramuscular (IM) injection.  After  administration of the injection, the nurse does which of the following first?      
    • A. 

      Recaps the needle

    • B. 

      Removes the gloves

    • C. 

      Washes the hands

    • D. 

      Places the syringe in the puncture resistant needle box container

  • 31. 
    A nurse is in the process of giving a client a bed bath.  In the middle of the procedure, the unit secretary calls the nurse on the intercom to tell the nurse that there is an emergency phone call.  The most appropriate nursing action is to:
    • A. 

      Leave the client’s door open so that client can be monitored and answer the phone call

    • B. 

      Finish the bath before answering the phone

    • C. 

      Immediately walk out of the client’s room and answer the phone call

    • D. 

      Cover the client, place the call light within reach, and the answer the phone call

  • 32. 
    • A. 

      To prevent falls

    • B. 

      To restrict movement of a limb

    • C. 

      To prevent the client from pulling out IV lines and catheters

    • D. 

      To prevent the violent client from injuring self and others

  • 33. 
    A nurse has an order to obtain a urinalysis from a client with an indwelling urinary catheter.  The nurse avoids which of the following that may contaminate the specimen?
    • A. 

      Obtaining the specimen from the urinary drainage bag

    • B. 

      Clamping the tubing on the drainage bag.

    • C. 

      Aspirating a sample from the port on the drainage bag.

    • D. 

      Wiping the port with an alcohol swab before inserting the syringe

  • 34. 
    • A. 

      Uses soap and water to cleanse the perineal area

    • B. 

      Keep the drainage bag above the level of the bladder

    • C. 

      Loops the tubing under the client’s leg

    • D. 

      Lets the drainage tubing rest under the leg.

  • 35. 
    A nurse is caring for an elderly client who had a hip pinned for a fractured hip.  In planning  nursing care, the nurse avoids which of the following to minimize the chance for further injury?
    • A. 

      Side rails in the up position

    • B. 

      Use of the night-light in hospital and bathroom.

    • C. 

      Call bell placed within the client’s reach

    • D. 

      Delays in responding to the call via the intercom that someone will attend to his or her needs.

  • 36. 
    • A. 

      Apply the restraint anyway

    • B. 

      Contact the physician

    • C. 

      Medicate the client with a sedative then apply the restraint

    • D. 

      Compromise with the client and use wrist restraints

  • 37. 
    A client is being discharged will receive oxygen therapy at home.  The nurse is teaching the client and family about oxygen safety measures.  Which of the following statements by the client indicates the need for further teaching?   
    • A. 

      I realize that I should check the oxygen level of portable tank on a consistent basis.

    • B. 

      I will keep my scented candles within 5 feet of my oxygen tank.

    • C. 

      I will not sit in front of my wood burning fireplace with my oxygen on.

    • D. 

      I will call the physician if I experienced any shortness of breath.

  • 38. 
    A home health nurse  visits a client who is to receive intravenous (IV) therapy via an IV pump.  The nurse notes that the electrical plug on the wall to be used for the IV pump has only two prongs.  Which of the following is the most appropriate action?
    • A. 

      Use the plug anyway

    • B. 

      Tape the electrical cord from the IV pump to the floor before plugging it in

    • C. 

      Run the electrical cord from the IV pump under the carpet before plugging it in

    • D. 

      Obtain a three-prong grounded plug adapter

  • 39. 
    • A. 

      Skid-resistant small area rugs in the living room

    • B. 

      Clothes hamper at the end of the hallway

    • C. 

      Area rugs on the stairs

    • D. 

      Carpeted stairs secured with carpet tacks

  • 40. 
    • A. 

      Restrain the client until the physician can be reached

    • B. 

      Call security to block all exit areas

    • C. 

      Tell the client that he can not return to this hospital again if he leaves now

    • D. 

      Call the nursing supervisor.

  • 41. 
    Two nurses are in the cafeteria having lunch in a quiet secluded area.  A physical therapist from P.T. department joins the nurses.  During lunch, the nurses discuss a client who was physically abused.  After lunch, the physical therapist provides therapy as prescribed to this physically abused client and asks the client questions about the physical abuse.  The client discovers that the nurses told the therapist about the abuse situation and is emotionally harmed.  The ramifications associated with the nurses' discussion about the client are most appropriately associated with which of the following?
    • A. 

      None, because the discussion took place in a quiet secluded area

    • B. 

      They can be charged with slander

    • C. 

      They can be charged with libel

    • D. 

      None, because the physical therapist is involved in the client’s care

  • 42. 
    • A. 

      Refuse to go to the ICU

    • B. 

      Go to the ICU, and tell the charge nurse he or she is ill and needs to go home

    • C. 

      Call the hospital lawyer

    • D. 

      Go to the ICU and inform the charge nurse of those tasks that cannot be performed

  • 43. 
    • A. 

      Request that the LPN review the materials from the inservice before performing the procedure.

    • B. 

      Request that the LPN review the procedure in the hospital manual and to bring the written procedure into the client’s room for guidance during the procedure

    • C. 

      Request that another LPN observe the procedure when it is performed

    • D. 

      Perform the procedure with the LPN

  • 44. 
    • A. 

      Administer the additional 0.100 mg

    • B. 

      Tell the client that the dose administered was not the total amount and administer the additional dose.

    • C. 

      Tell the client that too much medication was administered and an error was made.

    • D. 

      Complete an incident report

  • 45. 
    A nurse is preparing to transfer an average sized client with right-sided hemiplegia from the bed to the wheelchair. The client is able to support weight on the unaffected side. The nurse plans to use the hemiplegic transfer technique. The client is dangling on the side of the bed. For the safest transfer, the wheelchair should be positioned:        
    • A. 

      Near the client's right leg

    • B. 

      Next to either leg

    • C. 

      As space in the room permits

    • D. 

      Near the client's left leg

  • 46. 
    A nurse is caring for a client with a grave clinical condition who is a potential organ donor. Before approaching the family to discuss organ donation, the nurse reviews the client's medical record for contraindications to organ donation, which would include:    
    • A. 

      Allergy to penicillin - type antibiotics

    • B. 

      Age of 38 years

    • C. 

      Hepatitis B infection

    • D. 

      Negative rapid plasma reading ( RPR ) laboratory result

  • 47. 
    A nurse is monitoring the ongoing care given to the potential organ donor who has been diagnosed with brain death. The nurse evaluates that the standard of care had been maintained if which of the following data is observed?           
    • A. 

      Urine output 45 mL / hr

    • B. 

      Capillary refill 5 seconds

    • C. 

      Serum pH 7.32

    • D. 

      Blood pressure 90 / 48 mm Hg

  • 48. 
    A client who suffered a severe head injury had a vigorous treatment to control cerebral edema. Brain death has now been determined. The nurse prepares to carry out which of the following that will maintain viability of the kidneys before organ donation?
    • A. 

      Monitoring temperature

    • B. 

      Administering IV fluids

    • C. 

      Assessing lung sounds

    • D. 

      Performing range of motion exercises to extremities

  • 49. 
    A nurse is working in the emergency room of a small local hospital when a client with multiple gunshot wounds arrives by ambulance. Which of the following actions by the nurse is contraindicated in the proper care of handling legal evidence?
    • A. 

      Cut clothing along seams, avoiding bullet holes.

    • B. 

      Initiate a chain of custody log

    • C. 

      Place personal belongings in a labeled, sealed paper bag

    • D. 

      Give clothing and wallet to the family.

  • 50. 
    • A. 

      Bright red bleeding from a neck wound

    • B. 

      Penetrating abdominal injury

    • C. 

      Fractured tibia

    • D. 

      Open massive head injury in deep coma