NURSING COMPREHENSIVE EXAM 1
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- 1.
- A.
Ask frequently if the client understands the instructions.
- B.
Ask an interpreter to relay the instructions to the client.
- C.
Write out the instructions and have a family member read them to the client.
- D.
Demostrate the procedure to the client and have the client return the demonstration.
- 2.
- A.
A client with late-stage acquired immunodeficiency syndrome (AIDS).
- B.
A client with left-side paralysis after a cerebrovascular accident (CVA).
- C.
A client who is undergoing treatment for heroin addiction.
- D.
A client who had coronary artery bypass surgery 2 weeks ago.
- 3.
- A.
Scientific breakthroughs
- B.
Technological advances
- C.
Theoretical models
- D.
Medical practices
- 4.
- A.
Identify one way to increase social interaction
- B.
Report increased adaptation to changes in health status.
- C.
Identify at least one factor contributing to altered sexuality patterns.
- D.
Return a demonstration of measures that can increase independence
- 5.
- A.
Small decubitus ulcer noted on left leg.
- B.
Seems to be mad at the doctor.
- C.
Client had a good day.
- D.
Skin moist and cool.
- 6.
- A.
Assessment
- B.
Nursing diagnosis
- C.
Implementation
- D.
Evaluation
- 7.
- A.
Active bleeding
- B.
Reddened abscess
- C.
Edematous lower leg
- D.
Purulent wound drainage
- 8.
- A.
Decreased cardiac output
- B.
Ineffective thermoregulation
- C.
Ineffective breathing pattern
- D.
Altered renal tissue perfusion
- 9.To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), the nurse should palpate which pulse site?
- A.
Radial
- B.
Apical
- C.
Carotid
- D.
Brachial
- 10.
- A.
Clean from the center out in a circular
- B.
Remove the drain before cleansing the skin.
- C.
Clean briskly around the site with alcohol.
- D.
Wear sterile gloves and a mask.
- 11.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?
- A.
Reposition the client every 2 hours
- B.
Restrict fluids to 1,000 ml in 24 hours.
- C.
Administer oxygen by cannula as ordered.
- D.
Keep the head of the bed at a 30-degree angle.
- 12.A client with a fecal impaction typically exhibits which clinical manifestation?
- A.
Liquid or semi-liquid stools
- B.
Hard, brown formed stools
- C.
Loss of urge to defecate
- D.
Increased appetite
- 13.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?
- A.
Anxiety
- B.
Body image disturbance
- C.
Altered sexuality pattern
- D.
Ineffective individual coping
- 14.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?
- A.
Use the pump as is because the medication is ordered STAT.
- B.
Obtain another pump from central supply for the infusion
- C.
Tape the broken ground to the plug and use the pump.
- D.
Report the broken prong to the supervisor.
- 15.When obtaining a sterile urine specimen from an indwelling (Foley) catheter, which nursing action is appropriate to prevent infection?
- A.
Aspirate urine from the tubing port using a sterile syringe and needle.
- B.
Disconnect the catheter from the tubing and obtain urine.
- C.
Open the drainage bag and pour out some urine.
- D.
Wear sterile gloves when obtaining urine.
- 16.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?
- A.
Fear
- B.
Urinary retention
- C.
Fluid volume excess
- D.
Toileting self-care deficit
- 17.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?
- A.
Fear
- B.
Urinary retention
- C.
Fluid volume excess
- D.
Toileting self-care deficit
- 18.
- A.
Fatigue
- B.
High risk for injury
- C.
Activity intolerance
- D.
Sleep pattern disturbance
- 19.Which action is essential when the nurse provides a continuous enteral feeding?
- A.
Elevate the head of the bed.
- B.
Position the client on the left side.
- C.
Warm the formula before administering it.
- D.
Hang a full day's worth of formula at one time.
- 20.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?
- A.
Fresh orange slices
- B.
Ground beef patties
- C.
Steamed broccoli
- D.
Ice cream
- 21.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?
- A.
Administer the injection as prescribed
- B.
Call the physician and request an oral pain medication.
- C.
Withhold the injection until the client understands its importance
- D.
Explain that no other medication can be given until the client takes the injection.
- 22.
- A.
Assess the client's temperature every 8 hours.
- B.
Place the client in respiratory isolation
- C.
Monitor the client's fluid intake and output.
- D.
Wear gloves during all client contact
- 23.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?
- A.
Notify the Cancer Society of the client's diagnosis.
- B.
Request Meals On Wheels to provide adequate nutrition intake.
- C.
Refer the client to a home health nurse for follow-up visits to provide colostomy care.
- D.
Ask an occupational therapist to evaluate the client at home.
- 24.What is a common goal of discharge planning in all care settings?
- A.
Prolong hospitalization until the client can function independently.
- B.
Teach the client how to perform self-care.
- C.
Provide the financial resources needed to ensure proper care.
- D.
Prevent the need for further medical follow-up.
- 25.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?
- A.
Serum sodium level of 135 mEq/liter
- B.
Temperature of 99.6oF (37.5oC)
- C.
Neck vein distention
- D.
Dark amber urine
- 26.
- A.
Notify the physician.
- B.
Discontinue the infusion.
- C.
Administer the prescribed diuretic.
- D.
Slow the infusion and notify the physician.
- 27.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?
- A.
Instruct the client to cough
- B.
Ask the client to extend the tongue.
- C.
Tickle the uvula with a tongue blade
- D.
Observe while the client swallows sips of water.
- 28.After a cerebrovascular accident (CVA), a client develops aphasia. Which assessment finding most typifies aphasia?
- A.
Arm and leg weakness.
- B.
Absence of gag reflex.
- C.
Difficulty with swallowing.
- D.
Inability to speak clearly.
- 29.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?
- A.
Democratic
- B.
Permissive
- C.
Laissez-faire
- D.
Authoritarian
- 30.Which of the following addresses the client's rights to information, informed consent, and treatment refusal?
- A.
Standards of Nursing Practice
- B.
Patient's Bill of Rights
- C.
Nurse Practice Act
- D.
Code for Nurses
- 31.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.
- A.
Primary prevention
- B.
Secondary prevention
- C.
Tertiary prevention
- D.
Passive prevention
- 32.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?
- A.
Activity intolerance
- B.
Dysfunctional grieving
- C.
Altered role performance
- D.
Impaired physical mobility
- 33.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?
- A.
Obtain an order for a tranquilizer.
- B.
Limit visitors to 15 minutes per day.
- C.
Encourage the client to verbalize feelings
- D.
Reinforce the client's responsibility to the family.
- 34.Which question by the nurse would be most helpful when obtaining a health history from a client admitted with acute chest pain?
- A.
Do you need anything now?
- B.
Why do you think you had a heart attack?
- C.
What were you doing when the pain started?
- D.
Has anyone in your family been sick lately?
- 35.
- A.
Wear gloves whenever in contact with the client.
- B.
Consider all body substances potentially infectious.
- C.
Place a body substance isolation sign on the client's door.
- D.
Wear a gown and gloves when caring for a client in respiratory isolation.
- 36.
- A.
Instruct the client to notify the nurse if itching, swelling, or dyspnea occurs.
- B.
Inform the client that the transfusion usually takes 1 1/2 to 2 hours.
- C.
Document the blood administration in the client care record.
- D.
Assess the client's vital signs when the transfusion is completed
- 37.
- A.
5 ml
- B.
4.5 ml
- C.
2.5 ml
- D.
2.0 ml
- 38.
- A.
The skin is released before the needle is withdrawn.
- B.
The deltoid muscle is the preferred site for administration.
- C.
Aspiration is not necessary because the needle is inserted deep in the muscle layer.
- D.
The needle remains in place for 10 seconds after injection to allow the medication to disperse.
- 39.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?
- A.
Monitor urine output every hour.
- B.
Infuse I.V. fluids at 83 ml/hour
- C.
Administer oxygen by nasal cannula at 3 liters/minute
- D.
Draw specimens for hemoglobin and hematocrit every 6 hours.
- 40.Before performing a venipuncture to initiate continuous intravenous(IV) therapy, a nurse would:
- A.
Apply a tourniquet below the chosen vein site
- B.
Inspect the IV solution for particles or contamination
- C.
Secure an armboard to the joint located above the IV site
- D.
Place a cool compress over the vein
- 41.Which assessment is most important for the nurse to make before advancing a client from liquid to solid food?
- A.
Food preferences
- B.
Appetite
- C.
Presence of bowel sounds
- D.
Chewing ability
- 42.What method would a nurse use to most accurately assess the effectiveness of a weight loss diet for an obese client?
- A.
Daily weights
- B.
Serum protein levels
- C.
Daily calorie counts
- D.
Daily intake and output
- 43.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?
- A.
Stop the TPN
- B.
Decrease the flow rate of the TPN
- C.
Administer insulin
- D.
Notify the physician
- 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?
- A.
"What is your normal body temperature?"
- B.
"Do you experience frequent infections?"
- C.
"Do you have a family history of problems with general anesthesia?"
- D.
"Have you ever suffered from heat exhaustion or heat stroke?"
- 45.
- A.
Obtain a temperature to monitor for infection
- B.
Monitor the blood pressure (BP) to assess for fluid volume overload
- C.
Label the dressing with the date and time of catheter insertion
- D.
Prepare the client for a chest x-ray examination
- 46.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?
- A.
Respiratory Acidosis
- B.
Respiratory Alkalosis
- C.
Metabolic Acidosis
- D.
Metabolic Alkalosis
- 47.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?
- A.
Uncompensated metabolic alkalosis
- B.
Compensated metabolic acidosis
- C.
Uncompensated respiratory acidosis
- D.
Compensated respiratory alkalosis
- 48.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?
- A.
Metabolic Acidosis
- B.
Metabolic Alkalosis
- C.
Respiratory acidosis
- D.
Respiratory alkalosis
- 49.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?
- A.
Sodium of 145 mEq/L
- B.
Magnesium 2.0 mEq /L
- C.
Potassium 5.2 mEq/L
- D.
. Phosphorus 2.3 mEq/L
- 50.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?
- A.
Is isotonic with the plasma and other body fluids
- B.
Is hypotonic with the plasma and other body fluids
- C.
Does not affect the plasma osmolarity
- D.
Is the same solution as sodium chloride 0.9%
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