Nursing Comprehensive Exam 5

Reviewed by Allison Martin
Allison Martin, BSN |
School Nurse
Review Board Member
Allison Martin holds a Bachelor of Science in Nursing (BSN) from Drexel University's College of Nursing and Health Professions, specializing in neuroscience and cardiac care. She is dedicated to providing high-quality care and support to the school community as a School Nurse at St. Bernard's School, drawing on over 20 years of invaluable nursing experience.
 , BSN
By Mark Fredderick
Mark Fredderick, Certified Nursing Educator and Registered Nurse
Mark Fredderick Abejo is a Certified Nursing Educator and Registered Nurse with over 15 years of experience. His expertise spans nursing foundations, maternal-child care, medical-surgical nursing, and research. He holds an MA in Nursing Administration.
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  • 1/50 Questions

    A client with chronic renal failure is admitted with these findings:  pulse, 122 beats/minute; respirations, 32 breaths/minute; blood pressure, 190/110 mm Hg; neck vein distention; and bibasilar crackles.  Which nursing diagnosis should receive the highest priority?

    • Fear
    • Urinary retention
    • Fluid volume excess
    • Toileting self-care deficit
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About This Quiz

Nursing comprehensive exam quiz trivia! Nurses are helpers to the doctors, and they assist in ensuring that a patient gets back to being healthy. Some of the duties that nurses undertake include giving patient their medications as needed, checking their vitals, carrying different tests and helping the perform duties they would have done if they were healthy. Do take up this quiz and see if you know enough to be a good nurse.

Nursing Comprehensive Exam 5 - Quiz

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  • 2. 

    A client is admitted completely immobilized by an acute exacerbation of multiple sclerosis.  Two days after admission, the client cries frequently and refuses to see family members.  For this client, the nurse identifies a nursing diagnosis of hopelessness.  To address this diagnosis, the nurse should include which intervention in the client's plan of care?          

    • Obtain an order for a tranquilizer.

    • Limit visitors to 15 minutes per day.

    • Encourage the client to verbalize feelings

    • Reinforce the client's responsibility to the family.

    Correct Answer
    A. Encourage the client to verbalize feelings
    Explanation
    Encouraging verbalization of feelings is an example of therapeutic communication, which is used to help the client express and work through feelings and problems related to his or her condition. Administering drugs, limiting visits, and reminding the client of responsibilities are techniques that do not help the client work through feelings.

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  • 3. 

    A client is being discharged after undergoing abdominal surgery and colostomy formation to treat colon cancer.  When planning for this client's discharge, which nursing action is most likely to promote continuity of care? 

    • Notify the Cancer Society of the client's diagnosis.

    • Request Meals On Wheels to provide adequate nutrition intake.

    • Refer the client to a home health nurse for follow-up visits to provide colostomy care.

    • Ask an occupational therapist to evaluate the client at home.

    Correct Answer
    A. Refer the client to a home health nurse for follow-up visits to provide colostomy care.
    Explanation
    The first priority is to arrange for colostomy care, because many clients are discharged so quickly from acute care settings that they do not receive complete instructions. Notifying the American Cancer Society and requesting Meals On Wheels and an occupational therapy evaluation are important but can occur later in rehabilitation.

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  • 4. 

    Which of the following addresses the client's rights to information, informed consent, and treatment refusal?

    • Standards of Nursing Practice

    • Patient's Bill of Rights

    • Nurse Practice Act

    • Code for Nurses

    Correct Answer
    A. Patient's Bill of Rights
    Explanation
    The Patient's Bill of Rights addresses the client's rights to information, informed consent, timely responses to requests for services, and treatment refusal. It is a legal document and serves as guideline for decision making by the nurse. Standards of Nursing Practice, the Nurse Practice Act, and the Code for Nurse contain nursing practice parameters and primarily describe the use of the nursing process in providing care.

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  • 5. 

    Which question by the nurse would be most helpful when obtaining a health history from a client admitted with acute chest pain?

    • Do you need anything now?

    • Why do you think you had a heart attack?

    • What were you doing when the pain started?

    • Has anyone in your family been sick lately?

    Correct Answer
    A. What were you doing when the pain started?
    Explanation
    Subjective data (data from the client) about the chest pain help identify the specific health problem. For example, asking about the setting in which chest pain developed can provide necessary information about its cause. Options A and D do not elicit information related to a cardiac problem. Option B presumes a particular diagnosis and asks a "Why" question (a nontherapeutic technique).

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  • 6. 

    Which action is essential when the nurse provides a continuous enteral feeding?

    • Elevate the head of the bed.

    • Position the client on the left side.

    • Warm the formula before administering it.

    • Hang a full day's worth of formula at one time.

    Correct Answer
    A. Elevate the head of the bed.
    Explanation
    Elevating the head of the bed during an enteral feeding minimizes the risk of aspiration and allows the formula to flow into the intestines. When elevation of the head of the bed is contraindicated, the client should be positioned on the right side, not the left side. Enteral feedings should be given at room temperature to minimize GI distress. To limit microbial growth, the nurse should hang only the amount of formula that can be infused in 3 hours.

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  • 7. 

    A client is admitted with fatigue, anorexia, weight loss, and inability to sleep that started 1 month after the death of the client's spouse.  Which nursing diagnosis is most appropriate for this client?  

    • Activity intolerance

    • Dysfunctional grieving

    • Altered role performance

    • Impaired physical mobility

    Correct Answer
    A. Dysfunctional grieving
    Explanation
    Behavioral manifestations of dysfunctional grieving include alterations in eating habits, sleep patterns, and activity levels. None of the other nursing diagnoses include these manifestations among their defining characteristics.

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  • 8. 

    A client receives meperidine (Demerol), 50 mg I.M., for relief of surgical pain.  Thirty minutes later the nurse asks the client if the pain is relieved.  Which step of the nursing process is the nurse using?

    • Assessment

    • Nursing diagnosis

    • Implementation

    • Evaluation

    Correct Answer
    A. Evaluation
    Explanation
    Although the nurse is assessing pain relief, this action is considered part of the evaluation - not assessment - because the nurse has performed an intervention and is evaluating whether the goal has been met. During the nursing diagnosis step, the nurse labels or describes the client's health problems or needs, such as pain. During the implementation step, the nurse performs interventions to meet the client's needs, such as administering medication.

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  • 9. 

    What is a common goal of discharge planning in all care settings?      

    • Prolong hospitalization until the client can function independently.

    • Teach the client how to perform self-care.

    • Provide the financial resources needed to ensure proper care.

    • Prevent the need for further medical follow-up.

    Correct Answer
    A. Teach the client how to perform self-care.
    Explanation
    A common goal of discharge planning in all settings is teaching the client self-care. This action facilitates the transition between different settings and is designed to shorten hospital stays. Providing financial assistance is not a goal for discharge planning, although the nurse may make referrals to the appropriate department for financial assistance. The nurse should encourage the client to return for follow-up visits, rather than prevent them.

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  • 10. 

    To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), the nurse should palpate which pulse site?

    • Radial

    • Apical

    • Carotid

    • Brachial

    Correct Answer
    A. Carotid
    Explanation
    During CPR, the carotid artery is the most accessible and may persist when peripheral pulses (radial and brachial) are no longer palpable due to decreased cardiac output and decreased peripheral perfusion. The chest compressions performed during CPR make it impossible to accurately assess the apical pulse.

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  • 11. 

    Two days after undergoing a modified radical mastectomy, a client tells the nurse, "Now I won't be sexually attractive to my husband."  Based on this statement, which nursing diagnosis is most appropriate?      

    • Anxiety

    • Body image disturbance

    • Altered sexuality pattern

    • Ineffective individual coping

    Correct Answer
    A. Body image disturbance
    Explanation
    Body image disturbance is a disruption in the way one perceives one's body and is indicated by a verbal response to an actual change in physical appearance or structure. Anxiety may be present in this situation but is not specifically reflected in the client's statement. The client does not report an existing difficulty with sexual behavior, which would indicate an altered sexuality pattern She also has expressed an inability to cope.

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  • 12. 

    A client with chronic renal failure is admitted with these findings:  pulse, 122 beats/minute; respirations, 32 breaths/minute; blood pressure, 190/110 mm Hg; neck vein distention; and bibasilar crackles.  Which nursing diagnosis should receive the highest priority?

    • Fear

    • Urinary retention

    • Fluid volume excess

    • Toileting self-care deficit

    Correct Answer
    A. Fluid volume excess
    Explanation
    A client with renal failure does not eliminate sufficient fluid, which increases the risk of fluid overload and the resulting respiratory and electrolyte problems. This client is exhibiting signs of fluid volume excess and is acutely ill. Fear and toileting self-care deficit may be problems but are not as high a priority because they are not life-threatening. Urinary retention maybe a cause of renal failure but is not as urgent a concern as the fluid problem.

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  • 13. 

    A client is hospitalized with Pneumocystis carinii pneumonia.  The nurse observes that the client had no visitors, seems withdrawn, avoids eye contact, and refuses to engage in conversation.  In a loud and angry voice, the client demands that the nurse leave the room.  The nursing diagnosis for this client is social isolation.  Based on this diagnosis, what is an appropriate goal for this client's care?          

    • Identify one way to increase social interaction

    • Report increased adaptation to changes in health status.

    • Identify at least one factor contributing to altered sexuality patterns.

    • Return a demonstration of measures that can increase independence

    Correct Answer
    A. Identify one way to increase social interaction
    Explanation
    The goal for a client with a nursing diagnosis of social isolation is to identify at least one way to increase social interaction or to participate in social activities at least weekly. The other options are not goals that address the nursing diagnosis of social isolation.

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  • 14. 

    An employer has established a physical exercise area in the workplace and encourages all employees to use it. This is an example of what level of health promotion.

    • Primary prevention

    • Secondary prevention

    • Tertiary prevention

    • Passive prevention

    Correct Answer
    A. Primary prevention
    Explanation
    Primary prevention precedes disease and is applied to healthy clients. Secondary prevention focuses on clients who have health problems and are at risk for developing complications. Tertiary prevention is applied to clients who already have a disease or disability; it focuses on rehabilitation. Passive prevention enables clients to gain health from others' activities without doing anything themselves.

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  • 15. 

    Which intervention has the highest priority when a nurse is caring for a client receiving a blood transfusion?          

    • Instruct the client to notify the nurse if itching, swelling, or dyspnea occurs.

    • Inform the client that the transfusion usually takes 1 1/2 to 2 hours.

    • Document the blood administration in the client care record.

    • Assess the client's vital signs when the transfusion is completed

    Correct Answer
    A. Instruct the client to notify the nurse if itching, swelling, or dyspnea occurs.
    Explanation
    Because the administration of blood products may cause adverse effects, such as allergic reactions, the nurse must monitor the client for them. Signs and symptoms of life-threatening allergic reactions include itching, swelling, and dyspnea. The nurse should inform the client of the transfusion's duration and should document its administration. However, theses actions are not as critical to the client's immediate health. The nurse should assess the client's vital signs hourly during the transfusion.

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  • 16. 

    The nurse is preparing a client who speaks little English for discharge after emergency gallbladder surgery.  Which nursing action would be most effective in helping this client understand wound care instructions?

    • Ask frequently if the client understands the instructions.

    • Ask an interpreter to relay the instructions to the client.

    • Write out the instructions and have a family member read them to the client.

    • Demostrate the procedure to the client and have the client return the demonstration.

    Correct Answer
    A. Demostrate the procedure to the client and have the client return the demonstration.
    Explanation
    Demonstration by the nurse with a return demonstration by the client ensures that the client can perform wound care using the correct technique. Clients may claim to understand discharge instructions when they do not. An interpreter or family member may communicate the verbal or written instructions inaccurately.

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  • 17. 

    Which of the following clients would qualify for hospice care?

    • A client with late-stage acquired immunodeficiency syndrome (AIDS).

    • A client with left-side paralysis after a cerebrovascular accident (CVA).

    • A client who is undergoing treatment for heroin addiction.

    • A client who had coronary artery bypass surgery 2 weeks ago.

    Correct Answer
    A. A client with late-stage acquired immunodeficiency syndrome (AIDS).
    Explanation
    Hospices provide supportive, palliative care to terminally ill clients (such as those with late-stage AIDS) and their families. Hospice services would not be appropriate for the other clients because their health problems are not necessarily terminal.

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  • 18. 

    While preparing to start a STAT I.V. infusion, the nurse notices the ground on the infusion pump's plug is missing.  What should the nurse do first?    

    • Use the pump as is because the medication is ordered STAT.

    • Obtain another pump from central supply for the infusion

    • Tape the broken ground to the plug and use the pump.

    • Report the broken prong to the supervisor.

    Correct Answer
    A. Obtain another pump from central supply for the infusion
    Explanation
    Because safety is imperative for nurses and clients, the nurse should obtain another pump. Using the pump as is could lead to electrical shock. Damaged equipment should never be used, even if the nurse performs a temporary repair. It should be labeled "broken" and reported to the appropriate department for repair.

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  • 19. 

    After a cerebrovascular accident (CVA), a client develops aphasia.  Which assessment finding most typifies aphasia?       

    • Arm and leg weakness.

    • Absence of gag reflex.

    • Difficulty with swallowing.

    • Inability to speak clearly.

    Correct Answer
    A. Inability to speak clearly.
    Explanation
    Aphasia is the complete or partial loss of language skills caused by damage to cortical areas of the brain's left hemisphere. Arm and leg weakness may be present or the gag reflex may be absent after a CVA, but these are unrelated to aphasia. Difficulty with swallowing describes dysphagia.

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  • 20. 

    Each morning in the unit, the head nurse assigns clients and additional tasks to the nurses to be completed that day.  During the shift, a crisis develops and one of the staff nurses does not complete the additional tasks.  The next day, the staff nurse is reprimanded.  When the staff nurse tries to explain, the head nurse replies that the tasks should have been completed anyway.  Which these leadership styles is the head nurse exhibiting?     

    • Democratic

    • Permissive

    • Laissez-faire

    • Authoritarian

    Correct Answer
    A. Authoritarian
    Explanation
    The authoritarian leader retains all authority and responsibility and is concerned primarily with tasks and goal accomplishment. The democratic leader is people-centered, allows greater individual participation in decision making, and maintains open communication. The permissive or laissez-faire leader denies responsibility and abdicates authority to the group.

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  • 21. 

    A client is receiving an I.V. infusion of dextrose 5% in water and Ringer's lactate solution at 125 ml/hour to treat a fluid volume deficit.  Which of these signs indicates a need for additional I.V. fluids?

    • Serum sodium level of 135 mEq/liter

    • Temperature of 99.6oF (37.5oC)

    • Neck vein distention

    • Dark amber urine

    Correct Answer
    A. Dark amber urine
    Explanation
    Normally, urine appears light yellow; dark amber urine is concentrated and, in this client, suggests continued fluid volume deficit. The serum sodium level normally ranges from 135 to 145 mEq/liter. A temperature of 99.6oF (37.5oC) is only slightly elevated and does not indicate fluid volume deficit. Neck vein distention is a sign of fluid volume overload.

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  • 22. 

    For a hospitalized client, the physician prescribes meperidine (Demerol), 75 mg I.M., every 3 hours as needed for pain.  However, the client refuses to take injections.  Which nursing action is most appropriate?

    • Administer the injection as prescribed

    • Call the physician and request an oral pain medication.

    • Withhold the injection until the client understands its importance

    • Explain that no other medication can be given until the client takes the injection.

    Correct Answer
    A. Call the physician and request an oral pain medication.
    Explanation
    Adhering to the client's wishes and calling the physician for an oral pain medication is the most appropriate action. Administering an injection without client consent is considered battery and may lead to a lawsuit. Withholding medication without providing an alternative violates the standards of care. Any attempt to manipulate the client into taking the medication (as in option D) also violates the standards of care.

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  • 23. 

    When obtaining a sterile urine specimen from an indwelling (Foley) catheter, which nursing action is appropriate to prevent infection?   

    • Aspirate urine from the tubing port using a sterile syringe and needle.

    • Disconnect the catheter from the tubing and obtain urine.

    • Open the drainage bag and pour out some urine.

    • Wear sterile gloves when obtaining urine.

    Correct Answer
    A. Aspirate urine from the tubing port using a sterile syringe and needle.
    Explanation
    To obtain urine properly, the nurse should aspirate it from a port, using a sterile syringe after cleaning the port. Opening a closed urine drainage system, as in options B and C, increases the risk of urinary tract infection. Universal precautions specify the use of gloves during contact with body substances; however, sterile gloves are not necessary.

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  • 24. 

    Which assessment finding by the nurse would prohibit the application of a heating pad?         

    • Active bleeding

    • Reddened abscess

    • Edematous lower leg

    • Purulent wound drainage

    Correct Answer
    A. Active bleeding
    Explanation
    Heat application increases blood flow (vasodilation); therefore, it is contraindicated in active bleeding. For this same reason, however, applying heat to a reddened abscess, edematous lower leg, or wound with purulent drainage promotes healing.

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  • 25. 

    Which action by the nurse is essential when cleansing the area around a Jackson Pratt wound drain?

    • Clean from the center out in a circular

    • Remove the drain before cleansing the skin.

    • Clean briskly around the site with alcohol.

    • Wear sterile gloves and a mask.

    Correct Answer
    A. Clean from the center out in a circular
    Explanation
    The nurse should always swab around a wound drain, moving from the center outward in ever-enlarging circles. This technique is used because the skin near the drain site is more contaminated than the site itself. The drain should never be removed before cleansing the skin. Alcohol is never used to clean around the drain; it may irritate the skin and has no lasting effect on bacteria because it evaporates. The nurse should wear sterile gloves to prevent contamination, but a mask is not necessary.

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  • 26. 

    Which of these serves as a framework for nursing education and clinical practice?

    • Scientific breakthroughs

    • Technological advances

    • Theoretical models

    • Medical practices

    Correct Answer
    A. Theoretical models
    Explanation
    Theoretical models of nursing provide the foundation for all nursing knowledge. They also direct nursing practice based on the concepts of health, person, environment, and nursing. Scientific breakthroughs, technological advances, and medical practices may affect nursing but are not frameworks for nursing education and practice.

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  • 27. 

    What method would a nurse use to most accurately assess the effectiveness of a weight loss diet for an obese client?

    • Daily weights

    • Serum protein levels

    • Daily calorie counts

    • Daily intake and output

    Correct Answer
    A. Daily weights
    Explanation
    The most accurate measurement of weight loss is daily weighing of the client at the same time of the day, in the same clothes and using the same scale. Options B, C and D measure nutrition and hydration status.

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  • 28. 

    A client with diabetes mellitus has a blood glucose level of 644 mg/dL. The nurse interprets that this client is most at risk of developing which type of acid-base imbalance?          

    • Respiratory Acidosis

    • Respiratory Alkalosis

    • Metabolic Acidosis

    • Metabolic Alkalosis

    Correct Answer
    A. Metabolic Acidosis
    Explanation
    Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises. At the same time, the cells of the body utilize all available glucose. The body then breaks down glycogen and fat for fuel. The byproducts of fat metabolism are acidotic and can lead to the condition known as diabetic ketoacidosis. Options A, B, and D are incorrect

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  • 29. 

    A client is admitted to the hospital with a productive cough, night sweats, and fever.  Which of these actions is most important in the client's initial plan of care?  

    • Assess the client's temperature every 8 hours.

    • Place the client in respiratory isolation

    • Monitor the client's fluid intake and output.

    • Wear gloves during all client contact

    Correct Answer
    A. Place the client in respiratory isolation
    Explanation
    Because the client's signs and symptoms suggest a respiratory infection (possibly tuberculosis), respiratory isolation is indicated. Assessing the client's temperature every 8 hours is not frequent enough for a client with a fever. Monitoring fluid intake and output may be required, but placing the client in isolation should be done first. The nurse should wear gloves only for contact with mucous membranes, broken skin, and body substances.

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  • 30. 

    When caring for a client and following universal precautions, what is the nurse's primary responsibility?   

    • Wear gloves whenever in contact with the client.

    • Consider all body substances potentially infectious.

    • Place a body substance isolation sign on the client's door.

    • Wear a gown and gloves when caring for a client in respiratory isolation.

    Correct Answer
    A. Consider all body substances potentially infectious.
    Explanation
    Universal precautions are based on the concepts that all body substances are potentially infectious and that direct contact with them must be avoided. The nurse should wear gloves when contact with body substances is anticipated - not when in contact with unsoiled articles or intact skin. Because all body substances from all clients are considered potentially infectious, signs on doors are unnecessary. Gowns and gloves are inappropriate when caring for a client in respiratory isolation because they do not prevent the transmission of airborne respiratory infections; masks must be used as barriers to such infections.

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  • 31. 

    The physician prescribes the following preoperative medications to a client for I.M. administration: meperidine (Demerol), 50 mg; hydroxyzine (Vistaril), 25 mg; and glycopyrrolate (Robinul), 0.3 mg.  The medications are dispensed as follows: meperidine, 100 mg/ml; hydroxyzine, 100 mg/2 ml; and glycopyrrolate, 0.2 mg/ml.  How many milliliters, in total, should the nurse administer?    

    • 5 ml

    • 4.5 ml

    • 2.5 ml

    • 2.0 ml

    Correct Answer
    A. 2.5 ml
    Explanation
    Using the proportion method, the nurse solves for X in the following equations and then adds the total number of milliliters together as shown: (1 ml/100 mg = X ml/50 mg = 0.5 ml of meperidine) (2 ml/100 mg = X ml/25 mg = 0.5 ml of hydroxyzine) (1 ml/0.2 mg = X ml/0.3 mg = 1.5 ml of glycopyrrolate) (0.5 + 0.5 ml + 1.5 ml = 2.5 ml of all preoperative medications)

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  • 32. 

    Before performing a venipuncture to initiate continuous intravenous(IV) therapy, a nurse would:   

    • Apply a tourniquet below the chosen vein site

    • Inspect the IV solution for particles or contamination

    • Secure an armboard to the joint located above the IV site

    • Place a cool compress over the vein

    Correct Answer
    A. Inspect the IV solution for particles or contamination
    Explanation
    All IV solutions should be free of particles or precipitates. A tourniquet is to be applied above the chosen vein site. Cool compresses will cause vasoconstriction, making the vein less visible. Armboards are applied after the IV is started.

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  • 33. 

    A nurse is caring for a client with late stage salicylate poisoning who is experiencing metabolic acidosis. The client has a chemistry blood profile drawn. The nurse anticipates that which laboratory value is related to the client's acid-base disturbance?          

    • Sodium of 145 mEq/L

    • Magnesium 2.0 mEq /L

    • Potassium 5.2 mEq/L

    • . Phosphorus 2.3 mEq/L

    Correct Answer
    A. Potassium 5.2 mEq/L
    Explanation
    The client with late stage salicylate poisoning is at risk for metabolic acidosis because of the effects of acety salicylic acid in the body. Clinical manifestations of metabolic acidosis include hyperpnea with Kussmaul's respirations, headache, nausea, vomiting, diarrhea, fruity - smelling breath because of improper fat metabolism, central nervous system depression, twitching, convulsions, and hyperkalemia. The other laboratory values listed are within the normal reference ranges.

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  • 34. 

    A client with a cerebrovascular accident has a nursing diagnosis of ineffective airway clearance.  The goal for this client is to mobilize pulmonary secretions.  Which action should the nurse plan to take to meet this goal?           

    • Reposition the client every 2 hours

    • Restrict fluids to 1,000 ml in 24 hours.

    • Administer oxygen by cannula as ordered.

    • Keep the head of the bed at a 30-degree angle.

    Correct Answer
    A. Reposition the client every 2 hours
    Explanation
    Repositioning the client every 2 hours helps prevent secretions from pooling in dependent areas of the lungs. Fluid restriction makes secretions thicker and more tenacious, thus hindering secretion removal. Administering oxygen and keeping the head of the bed at 30 degrees may make the client's respirations easier and more effective, but these interventions do not help mobilize secretions.

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  • 35. 

    A client is admitted with multiple decubitus ulcers.  To promote healing, the nurse should include which of these foods in the client's diet plan?

    • Fresh orange slices

    • Ground beef patties

    • Steamed broccoli

    • Ice cream

    Correct Answer
    A. Ground beef patties
    Explanation
    The client needs protein to repair the tissue breakdown from the decubitus ulcers, and meat is an excellent source of complete protein. Oranges and broccoli supply vitamin C but not protein. Ice cream supplies some incomplete protein, making it less helpful in tissue repair.

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  • 36. 

    For a hospitalized client, which statement reflects appropriate documentation in the client's medical record?       

    • Small decubitus ulcer noted on left leg.

    • Seems to be mad at the doctor.

    • Client had a good day.

    • Skin moist and cool.

    Correct Answer
    A. Skin moist and cool.
    Explanation
    Documentation should include data obtained by the nurse using only observations that are heard, seen, smelled, or felt. The nurse should record findings or observations precisely and accurately. Documentation of a leg ulcer should include its exact size and location. Documentation of observed client behaviors or conversations is appropriate, but drawing conclusions about a client's feelings is not. Stating that the client had a good day is not precise enough information to be useful.

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  • 37. 

    After a bronchoscopy, the client must receive nothing by mouth until the gag reflex returns.  What is the best way to assess for return of the gag reflex?            

    • Instruct the client to cough

    • Ask the client to extend the tongue.

    • Tickle the uvula with a tongue blade

    • Observe while the client swallows sips of water.

    Correct Answer
    A. Tickle the uvula with a tongue blade
    Explanation
    By tickling the uvula with a tongue blade, the nurse can assess the gag reflex safety and accurately. The nurse may encourage coughing to maintain an open airway, but not to assess.The gag tongue extension is not a reliable gauge of the gag reflex because the client can extend the tongue before the ability to swallow returns. The nurse should not provide fluids before verifying that gag reflex has returned.

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  • 38. 

    Which assessment is most important for the nurse to make before advancing a client from liquid to solid food?

    • Food preferences

    • Appetite

    • Presence of bowel sounds

    • Chewing ability

    Correct Answer
    A. Chewing ability
    Explanation
    It may be necessary to modify a client’s diet to a soft or mechanically chopped diet if the client has difficulty chewing. Food preferences should be ascertained on admission assessment. Appetite will affect the amount of food eaten, but not the type of diet ordered. Bowel sounds should be present before introducing any diet, including liquids.

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  • 39. 

    A client with congestive heart failure has been receiving an I.V. infusion at 125 ml/hour. Now the client is short of breath, and the nurse notes bilateral crackles, neck vein distention, and tachycardia.  What should the nurse do first?     

    • Notify the physician.

    • Discontinue the infusion.

    • Administer the prescribed diuretic.

    • Slow the infusion and notify the physician.

    Correct Answer
    A. Slow the infusion and notify the physician.
    Explanation
    Because this client shows signs of fluid overload, the nurse should slow the infusion first to prevent additional fluid overload and then notify the physician and obtain further orders. Notifying the physician without slowing the infusion puts the client at risk for pulmonary complications or respiratory failure. Discontinuing the infusion is inappropriate because vascular access still may be needed to administer I.V. fluids (at a decreased rate) or additional I.V. medications. Administering a diuretic without changing the I.V. infusion rate cannot prevent fluid overload from recurring.

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  • 40. 

    A nurse performs a fingerstick glucose test on a client receiving total parenteral nutrition (TPN).   Results show the client’s glucose level to be greater than 400 mg/dL.   What nursing action is most appropriate at this time? 

    • Stop the TPN

    • Decrease the flow rate of the TPN

    • Administer insulin

    • Notify the physician

    Correct Answer
    A. Notify the physician
    Explanation
    Hyperglycemia is a complication of TPN, and nurse reports abnormalities to the physician. Options A, B and C are not done without a physician’s order.

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  • 41. 

    A 1000-mL intravenous ( IV ) solution of normal saline solution 0.9% is prescribed for the client. The nurse understands that which of the following is not a characteristics of this type of solution?

    • Is isotonic with the plasma and other body fluids

    • Is hypotonic with the plasma and other body fluids

    • Does not affect the plasma osmolarity

    • Is the same solution as sodium chloride 0.9%

    Correct Answer
    A. Is hypotonic with the plasma and other body fluids
    Explanation
    Sodium chloride 0.9% is the same solution as normal saline solution 0.9%. This solution is isotonic, and isotonic solutions are frequently used for IV infusion because they do not affect the plasma osmolarity.

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  • 42. 

    A client with a fecal impaction typically exhibits which clinical manifestation?

    • Liquid or semi-liquid stools

    • Hard, brown formed stools

    • Loss of urge to defecate

    • Increased appetite

    Correct Answer
    A. Liquid or semi-liquid stools
    Explanation
    The passage of liquid or semi-liquid stools results from seepage of unformed bowel contents around the impacted stool in the rectum. Clients with fecal impaction do not pass hard, brown formed stools because the feces cannot move past the impaction. Clients usually report the urge to defecate - though they cannot pass stool - and decreased appetite.

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  • 43. 

    A client with congestive heart failure has not slept for the past three nights due to dyspnea.  The client's arterial blood gas (ABG) values are pH, 7.32; PaO2, 79; PaCO2, 50; and HCO3, 29.  Which nursing diagnosis should receive the highest priority for this client?           

    • Fatigue

    • High risk for injury

    • Activity intolerance

    • Sleep pattern disturbance

    Correct Answer
    A. High risk for injury
    Explanation
    The client's ABG values reveal hypoxia (insufficient oxygen in the blood), which causes altered thought processes and thus is associated with a high risk for injury. Fatigue, activity intolerance, and sleep pattern disturbance may apply to this client, but safety is the first concern.

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  • 44. 

    A nurse is assessing a preoperative client.  Which of the following questions will help the nurse determine the client’s risk for developing malignant hyperthermia postoperatively?          

    • "What is your normal body temperature?"

    • "Do you experience frequent infections?"

    • "Do you have a family history of problems with general anesthesia?"

    • "Have you ever suffered from heat exhaustion or heat stroke?"

    Correct Answer
    A. "Do you have a family history of problems with general anesthesia?"
    Explanation
    Malignant hyperthermia is genetic disorder in which a combination of anesthetic agents (succinylcholine and inhalation agents such as halothanes) trigger uncontrolled skeletal muscle contractions. This quickly leads to a potentially fatal hyperthermia. Questioning the client about any family history of general anesthesia problems may reveal this as a possibility for the client. Options A, B and D are unrelated to this surgical complication.

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  • 45. 

    A client with shock due to hemorrhage has these vital signs: temperature 97.6oF (36.4oC); pulse, 140 beats/minute; respirations, 28 breaths/minute; and blood pressure, 60/30 mm Hg. For this client, the nurse should question which physician order?   

    • Monitor urine output every hour.

    • Infuse I.V. fluids at 83 ml/hour

    • Administer oxygen by nasal cannula at 3 liters/minute

    • Draw specimens for hemoglobin and hematocrit every 6 hours.

    Correct Answer
    A. Infuse I.V. fluids at 83 ml/hour
    Explanation
    Because shock signals a severe fluid volume loss (750 to 1,300 ml), its treatment includes rapid replacement of I.V. fluids to promote homeostasis and prevent death. In fact, the nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An I.V. rate of 83 ml/hour cannot begin to replace the necessary fluids and reverse the problem. The remaining options are appropriate orders for this client.

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  • 46. 

    A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurses assesses the client for symptoms of which acid-base disorder?        

    • Metabolic Acidosis

    • Metabolic Alkalosis

    • Respiratory acidosis

    • Respiratory alkalosis

    Correct Answer
    A. Metabolic Alkalosis
    Explanation
    Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis. This is because of the loss of hydrochloric acid, which is a potent acid in the body. Thus this situation results in an alkalotic condition. The respiratory system is not involved.

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  • 47. 

    A client is admitted with the following vital signs: temperature, 102oF (38.8oC); pulse, 144 breaths/minute and irregular; and respirations, 26 breaths/minute.  Which nursing diagnosis has the highest priority when planning this client's care?            

    • Decreased cardiac output

    • Ineffective thermoregulation

    • Ineffective breathing pattern

    • Altered renal tissue perfusion

    Correct Answer
    A. Decreased cardiac output
    Explanation
    A heart rate 144 beats/minute indicates a decreased diastolic filling time and a reduced amount of blood ejected with each contraction, which results in decreased cardiac output. The client's temperature and respiratory rate are elevated, but not enough to take precedence over decreased cardiac output. The client's vital signs do not suggest altered renal tissue perfusion.

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  • 48. 

    A nurse is reviewing the client's most recent blood gas results and the results indicate a pH of 7.42, PaCO2 of 31 mm Hg, and HCO3 of 21 mEq/ L. The nurse interprets these results as indicative of which acid-base imbalance?    

    • Uncompensated metabolic alkalosis

    • Compensated metabolic acidosis

    • Uncompensated respiratory acidosis

    • Compensated respiratory alkalosis

    Correct Answer
    A. Compensated respiratory alkalosis
    Explanation
    The normal pH is 7.35 to 7.45. The normal PaCO2 is 35 to 45 mm Hg and the normal HCO3 is 22 to 27 mEq/L. The pH is elevated in alkalosis and low in acidosis. In a respiratory condition, an opposite effect will be seen between the pH and the PaCO2. In a metabolic condition, the pH and the bicarbonate move in the same direction. Since the pH is within the normal range of 7.35 to 7.45, compensation has occurred.

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  • 49. 

    Which statement accurately characterizes the Z-track method for I.M. injections?

    • The skin is released before the needle is withdrawn.

    • The deltoid muscle is the preferred site for administration.

    • Aspiration is not necessary because the needle is inserted deep in the muscle layer.

    • The needle remains in place for 10 seconds after injection to allow the medication to disperse.

    Correct Answer
    A. The needle remains in place for 10 seconds after injection to allow the medication to disperse.
    Explanation
    D In the Z-track method for I.M. injections, which is used for medications that cause irritation or discolor subcutaneous tissue, the needle should remain in place for 10 seconds to allow the medication to dispense. The skin is released after the needle is withdrawn to seal medication in the muscle tissue. Deltoid muscles are used infrequently for Z-track injections because they are small and their use increases the risk of injuring the brachial or radial nerve. Aspiration must be done for Z-track and all other I.M. injections to check for blood.

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Allison Martin |BSN |
School Nurse
Allison Martin holds a Bachelor of Science in Nursing (BSN) from Drexel University's College of Nursing and Health Professions, specializing in neuroscience and cardiac care. She is dedicated to providing high-quality care and support to the school community as a School Nurse at St. Bernard's School, drawing on over 20 years of invaluable nursing experience.

Quiz Review Timeline (Updated): Mar 9, 2025 +

Our quizzes are rigorously reviewed, monitored and continuously updated by our expert board to maintain accuracy, relevance, and timeliness.

  • Current Version
  • Mar 09, 2025
    Quiz Edited by
    ProProfs Editorial Team

    Expert Reviewed by
    Allison Martin
  • Apr 13, 2012
    Quiz Created by
    Mark Fredderick
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