NURSING COMPREHENSIVE EXAM 2

50 Questions
Nursing Quizzes & Trivia
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Questions and Answers
  • 1. 
    A client with a burn injury is transferred to the nursing unit, and a regular diet has been prescribed. Which dietary items should the nurse encourage the client to eat in order to promote wound healing?      
    • A. 

      Veal, potatoes, Jell - O, Orange juice

    • B. 

      Peanut butter and jelly, cantaloupe, tea

    • C. 

      Chicken breast, Broccoli, Strawberries, Milk

    • D. 

      Spaghetti with tomato sauce, Garlic bread, Ginger ale

  • 2. 
    A nurse is preparing to access an implanted vascular port to administer chemotherapy. The nurse:            
    • A. 

      Anchors the port with the dominant hand

    • B. 

      Palpates the port to locate the center of the septum

    • C. 

      Places a warm pack over the area for several minutes to alleviate possible discomfort

    • D. 

      Cleans the area with alcohol working from the outside inward

  • 3. 
    A nurse has assisted the physician with a liver biopsy that was done at the bedside. On completion of the procedure, the nurse assists the client into which of the following positions?     
    • A. 

      Left side - lying with a small pillow or towel under the puncture site

    • B. 

      Right side - lying with a small pillow or towel under the puncture site

    • C. 

      Left side - lying with the right arm elevated above the head

    • D. 

      Right side - lying with the left arm elevated above the head

  • 4. 
    • A. 

      Left - lateral Sims' position

    • B. 

      Right - lateral Sims' position

    • C. 

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

    • D. 

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

  • 5. 
    A physician had just inserted a Cantor tube in a client with bowel obstruction. When the procedure is complete, the nurse assists the client into which of the following positions initially to maximize the effect of the tube?
    • A. 

      Right side

    • B. 

      Left side

    • C. 

      Prone

    • D. 

      Supine

  • 6. 
    A nurse is caring for a client following craniotomy who has a supratentorial incision. The nurse places a sign above the client's bed stating that the client should be maintained in which of the following positions?
    • A. 

      Semi fowler

    • B. 

      Dorsal recumbent

    • C. 

      Prone

    • D. 

      Supine

  • 7. 
    • A. 

      10ml

    • B. 

      12ml

    • C. 

      13ml

    • D. 

      14ml

  • 8. 
    A client is unable  to expectorate to yield a sputum sample  and the nurse decides  to use the saline  inhalation  method to  obtain the sample. The nurse instructs the client to inhale the warm saline vapor via nebulizer by:
    • A. 

      Holding the nebulizer under the nose

    • B. 

      Keeping the lips closed lightly over the mouthpiece

    • C. 

      Keeping the lips closely tightly over the mouthpiece

    • D. 

      Alternating one vapor breath with one breath from room air

  • 9. 
    • A. 

      Suctioning the client's airway

    • B. 

      Rinsing it with sterile water

    • C. 

      Tapping it against a sterile surface to dry it

    • D. 

      Drying it thoroughly with a sterile gauze

  • 10. 
    A nurse suspects  that an air embolism has occurred in a client  receiving  total  parenteral nutrition(TPN)  through a central nervous catheter when the central line disconnects from the IV tubing. The nurse  immediately turns the client  to the:
    • A. 

      Left side with the head higher than the feet

    • B. 

      Right side with the head higher than the feet

    • C. 

      Left side with the feet higher than the head

    • D. 

      Right side with the feet higher than the head

  • 11. 
    An anxious client enters  the emergency department  seeking the treatment  for a laceration of the finger that occurred when using  a power tool. The client's  vital signs are pulse (P) 96 beats/min, blood pressure (BP) 148/88 mm Hg, and respirations (R) 24 breaths/min. After cleansing  the injury and reassuring  the client, the nurse rechecks the vital signs and notes P 82 beats/min,BP 130/80 mm Hg, and R 20 breaths/min. The change  in vital signs is caused by:           
    • A. 

      Reduced stimulation of the sympathetic nervous system

    • B. 

      The cooling effects of the cleansing solution

    • C. 

      The body's physical adaptation to the air conditioning

    • D. 

      Possible impending cardiovascular collapse

  • 12. 
    • A. 

      Chest x-ray examination in the morning ,echocardiogram in the afternoon, and the CT scan the morning of the following day

    • B. 

      Chest x-ray examination and echocardiogram together in the morning, and the CT scan in the afternoon of the same day

    • C. 

      Echocardiogram in the morning, and the chest x-ray examination and CT scan together in the afternoon of the same day

    • D. 

      CT scan in the morning, and the chest x-ray examination and echocardiogram on the following morning

  • 13. 
    • A. 

      Discarded properly and recorded as output on the client’s I&O record.

    • B. 

      Poured into the nasogastric tube through a syringe with the plunger removed

    • C. 

      Mixed with the formula and poured into the nasogastric tube through a syringe without a plunger

    • D. 

      Diluted with water and injected into the nasogastric tube by putting pressure on the plunger

  • 14. 
    A multi disciplinary team has been working with a home care client who has an end-stage liver failure and has been teaching the spouse interventions for the management of pain.  Which statement by the spouse indicates the need for further teaching?
    • A. 

      " If the pain increases, I must let the nurse know immediately."

    • B. 

      "I should have my husband try the breathing exercises to control the pain."

    • C. 

      "This narcotic will cause very deep sleep, which is what my husband needs."

    • D. 

      "If constipation is a problem, increased fluids will help."

  • 15. 
    A home care nurse finds a client in the bedroom, unconscious, with pill bottle in hand.  The pill bottle contained the selective serotonin reuptake inhibitor (SSRI) sertraline (Zoloft).  The nurse immediately assess the client’s:         
    • A. 

      Blood pressure

    • B. 

      Respirations

    • C. 

      Pulse

    • D. 

      Urinary output

  • 16. 
    A nurse is checking a unit of blood from the blood bank and notes the presence of gas bubbles in the bag.  The nurse should take which of the following actions?          
    • A. 

      Add 10 mL of normal saline solution to the bag

    • B. 

      Agitate the bag gently to mix contents

    • C. 

      Add 100 units of heparin to the bag

    • D. 

      Return the blood to the blood bank

  • 17. 
    A nurse has an order to infuse a unit of blood.  The nurse checks the client’s intravenous line to make sure that the gauge of the intravenous catheter is at least:     
    • A. 

      14

    • B. 

      19

    • C. 

      22

    • D. 

      24

  • 18. 
    • A. 

      Recheck the unit of blood for compatibility

    • B. 

      Check the client’s temperature

    • C. 

      Stop the transfusion

    • D. 

      Call the physician

  • 19. 
    A nurse has an order to discontinue the nasogastric tube of an assigned client.  After explaining to the client, the nurse raises the bed to semi-Fowlers position, places a towel across the chest, clear the tube with normal saline, clamps the tube, and removes the tube           
    • A. 

      During inspiration

    • B. 

      During expiration

    • C. 

      After inspiration, but before expiration

    • D. 

      After expiration, but before inspiration

  • 20. 
    A nurse is caring for a client who has as order to receive an intravenous intralipid infusion.  Which of the following actions does the nurse takes as part of proper procedure before hanging the infusion?
    • A. 

      Add 100 mL of normal saline solution to the bottle

    • B. 

      Attach an in-line filter

    • C. 

      Remove the bottle from the refrigerator

    • D. 

      Check the solution for separation or an oily appearance

  • 21. 
    A nurse is administering continuous tube feedings to a client.  The nurse takes which of the following actions as part of routine for this client? 
    • A. 

      Checks the residual every 4 hours

    • B. 

      Changes the feeding bag and tubing every 12 hours

    • C. 

      Pours additional feeding into the bag when 25 ml are left

    • D. 

      Holds the feeding if greater than 200 mL are aspirated.

  • 22. 
    In a client receiving total parenteral nutrition (TPN), chest pain, dyspnea, tachycardia, cyanosis, and decreased level of consciousness suddenly develop.  The nurse suspects which complication of TPN?     
    • A. 

      Hyperglycemia

    • B. 

      Catheter-related sepsis

    • C. 

      Allergic reaction to the TPN catheter

    • D. 

      Air embolism

  • 23. 
    The nurse suspects the occurrence of an air embolism in a client with a triple-lumen catheter. If an air embolism is present, the nurse would most likely note which of the following?          
    • A. 

      Hypertension

    • B. 

      Diminished breath sounds

    • C. 

      A churning sound heard over the right ventricle on auscultation

    • D. 

      Rales heard in the lung bases on auscultation

  • 24. 
    • A. 

      On their side with the knee of the uppermost leg flexed

    • B. 

      On their side with the knee of the lowermost leg flexed

    • C. 

      Prone with a toe-in position

    • D. 

      Sims’ with a toe-in position

  • 25. 
    A nurse plans to administer a medication by IV bolus through the IV primary line.    The nurse notes that the medication is incompatible with the primary IV solution.   The most appropriate nursing action to safely administer the medication is to:        
    • A. 

      Call the physician for an order to change the route of the medication

    • B. 

      Start a new IV line for the medication

    • C. 

      Flush the tubing before and after the medication with normal saline

    • D. 

      Flush the tubing before and after the medication with sterile water

  • 26. 
    A client has a serum sodium level of 129 mEq/L as a result of hypervolemia. The nurse consults with the physician to determine whether which of the following most appropriate measures should be instituted?   
    • A. 

      Providing a 2-g sodium diet

    • B. 

      Providing a 4-g sodium diet

    • C. 

      Fluid restriction

    • D. 

      Administering intravenous hypertonic saline

  • 27. 
    A nurse is caring for a client with a nursing diagnosis of Altered Oral Mucous Membranes. The nurse would avoid using which of the following items when giving mouth care of this client?         
    • A. 

      Nonalcoholic mouthwash

    • B. 

      Soft toothbrush

    • C. 

      Lip moistener

    • D. 

      Lemon-glycerin swabs

  • 28. 
    A client has a pH of 7.51 with a bicarbonate level of 29 mEq/L.  The nurse prepares to administer which of the following medications that would be ordered to treat this acid-base disorder?
    • A. 

      Sodium bicarbonate

    • B. 

      Furosemide (Lasix)

    • C. 

      Acetazolamide (Diamox)

    • D. 

      Spiranolactone (Aldactone)

  • 29. 
    A client is admitted to the hospital in metabolic acidosis caused by diabetic ketoacidosis (DKA).  The nurse prepares to administer which of the following medications as a primary initial treatment for this problem?  
    • A. 

      Sodium bicarbonate

    • B. 

      Calcium gluconate

    • C. 

      Potassium

    • D. 

      Insulin

  • 30. 
    A client is diagnosed with respiratory alkalosis induced by gram-negative sepsis. The nurse carries out which of the following prescribed measures as the most effective means to treat the problem?    
    • A. 

      Administers prescribed antibiotics

    • B. 

      Administers PRN antipyretics

    • C. 

      Has the client breathe into a paper bag

    • D. 

      Requests an order for a partial rebreather oxygen mask

  • 31. 
    A nurse is preparing to administer an intramuscular injection to a 2-year-old child. The best site to select for the injection is the:            
    • A. 

      Ventral gluteal muscle

    • B. 

      Dorsal gluteal muscle

    • C. 

      Deltoid muscle

    • D. 

      Vastus lateralis muscle

  • 32. 
    A nurse instructs the client about the procedure to perform the Breast Self-Examination (BSE). Which client statement indicates a need for further instructions?
    • A. 

      "I don’t need to do that, I'm too old for that."

    • B. 

      "I do BSE 7 days after I get my period."

    • C. 

      "I examine my breasts in the shower."

    • D. 

      "I lie on my back to examine my breast."

  • 33. 
    A nurse notes redness, warmth, and a purulent drainage at the insertion site of a central venous catheter in a client receiving total parenteral nutrition (TPN). The nurse notifies the physician of this finding because:      
    • A. 

      Infections of the central catheter site can lead to septicemia

    • B. 

      The client is experiencing an allergy to the TPN solution

    • C. 

      The TPN solution has infiltrated and must be stopped

    • D. 

      The client is allergic to the dressing material covering the site

  • 34. 
    A nurse is assisting in positioning a client for a surgical procedure. The nurse knows that the respiratory system is most vulnerable to which of the following positions?
    • A. 

      Lithotomy

    • B. 

      Supine

    • C. 

      Lateral

    • D. 

      Sims

  • 35. 
    A client has returned to the nursing unit following an abdominal hysterectomy. The client is lying supine. To completely assess the client for postoperative bleeding, the nurse should do which of the following?
    • A. 

      Check the abdominal dressing

    • B. 

      Check the perineal pad

    • C. 

      Ask the client about a sensation of moistness

    • D. 

      Roll the client to one side after checking the perineal pad and the abdominal dressing

  • 36. 
    A nurse employed in a long- term care facility is planning the client assignments for the shift. Which of the following clients would the nurse most appropriately assign to the nursing assistant (NA)?
    • A. 

      A client requiring BID dressing changes

    • B. 

      A client requiring frequent ambulation

    • C. 

      A client on a bowel management program requiring rectal suppositories and a daily enema

    • D. 

      A client with diabetes mellitus requiring daily insulin and reinforcement of dietary measures

  • 37. 
    A physician asks a nurse to discontinue the feeding tube in a client who is in a chronic vegetative state. The physician tells the nurse that the request  was  made  by  the  client’s spouse and children. The nurse understands the legal basis for carrying out the order and first checks the client’s record for documentation of:
    • A. 

      A court approval to discontinue the treatment

    • B. 

      A written order by the physician to remove the tube

    • C. 

      Authorization by the family to discontinue the treatment

    • D. 

      Approval by the institutional ethics committee

  • 38. 
    A nurse is caring for a client receiving total parental nutrition (TPN). The nurse implements which action to decrease the risk of infection?         
    • A. 

      Assessing vital signs at 4-hour intervals

    • B. 

      Instructing the client to perform a Valsalva maneuver during intravenous tubing changes

    • C. 

      Administer acetaminophen (Tylenol) before changing the central line dressing

    • D. 

      Using aseptic technique in handling the TPN solution and tubing

  • 39. 
    A nurse provides medication instructions to a home health care client. To ensure safe administration of medication in the home, the nurse:         
    • A. 

      Demonstrates the proper procedure for taking prescribed medications

    • B. 

      Allows the client to verbalize and demonstrate correct administration procedures

    • C. 

      Instructs the client that it is OK to double up on medications if a dose has been missed

    • D. 

      Conducts pill counts on each home visit

  • 40. 
    A nurse plans to carry out a multidisciplinary research project on the effects of immobility on clients’ stress levels. The nurse understands that which principle is most important when planning this project?       
    • A. 

      Collaboration with other disciplines is essential to the successful practice of nursing

    • B. 

      The corporate nurse executive should be consulted, because the project will take nursing time

    • C. 

      All clients have the right to refuse to participate in research using human subjects

    • D. 

      The cooperation of the physicians on staff must be ensured for the project to succeed

  • 41. 
    A nurse has an order to obtain a sputum from a client admitted to the hospital with a diagnosis of pneumonia. The nurse avoids which action when obtaining the specimens?
    • A. 

      Placing the lid of the culture container face down on the bedside table

    • B. 

      Obtaining the specimen early in the morning

    • C. 

      Having the client brush teeth before expectoration

    • D. 

      Instructing the client to take deep breaths before coughing

  • 42. 
    A nurse has inserted a nasogastric tube (NG) into the stomach of a client and prepares to check for accurate tube placement.   The nurse avoids which least reliable method for checking the tube placement?
    • A. 

      Aspirating the tube with a 50-mL syringe to obtain gastric contents

    • B. 

      Measuring the pH of gastric aspirate

    • C. 

      Placing the end of the tube in water to check for bubbling

    • D. 

      Instilling 10 to 20 mL of air into the tube while auscultating over the stomach

  • 43. 
    A nurse is performing a bladder catheterization and is inserting an indwelling Foley catheter.   The nurse understands that which of the following represents an incorrect action when performing this procedure?
    • A. 

      Inflating the balloon to test patency before catheter insertion

    • B. 

      Advancing the catheter just until urine appears in the catheter tubing

    • C. 

      Inflating the balloon with 4 to 5 mL more than the balloon capacity

    • D. 

      Placing the bag lower than bladder level, with no kinks in the tubing

  • 44. 
    • A. 

      Moves the client rapidly from the table to the stretcher

    • B. 

      Uncovers the client completely before transferring to the stretcher

    • C. 

      Secures the client with safety belts after transferring to the stretcher

    • D. 

      Instructs the client to move himself or herself from the table to the stretcher

  • 45. 
    • A. 

      Request that the friend come to the client’s home where she can be taught to administer the feedings.

    • B. 

      Inform the friend to directly contact the family and offer her assistance to them

    • C. 

      Report the friend’s telephone call to the nurse manager for referral to the client’s social worker

    • D. 

      Inform the friend that the family has no need for assistance at this time because the nurse is making daily visits

  • 46. 
    A nurse is caring a client with cancer. The client tells the nurse that a lawyer will be arriving today to prepare a living will. The client asks the nurse to act as one of the witnesses for the will. The most appropriate nursing action is to:
    • A. 

      Agree to act as a witness

    • B. 

      Refuse to help the client

    • C. 

      Inform the client that a nurse caring for a client cannot serve as a witness to a living will

    • D. 

      Call the physician

  • 47. 
    A client diagnosed with leukemia asks the nurse question about preparing a living will. The nurse informs the client that the initial step in preparing this document is to:           
    • A. 

      Consult with the American Cancer Society

    • B. 

      Talk to the hospital chaplain

    • C. 

      Contact a lawyer

    • D. 

      Discuss the request with the physician

  • 48. 
    A client is admitted to the hospital for a bowel resection following a diagnosis of a bowel tumor.  During the admission assessment, the client tells the nurse that a living will was prepared three years ago.   The client asks the nurse if this document is still effective.   The most appropriate nursing response is which of the following?         
    • A. 

      Yes it is.

    • B. 

      You will have to ask your lawyer

    • C. 

      It should be reviewed yearly with your physician.

    • D. 

      I have no idea.

  • 49. 
    A home care visits a client recently discharge from the hospital following an acute myocardial infraction.  The client tells the nurse that a living  will was prepared and asks the nurse where a copy of the will can be  obtained.  The nurse tells the client that which area will not have a copy?  
    • A. 

      Lawyer’s office

    • B. 

      Physician’s office

    • C. 

      Medical record and hospital

    • D. 

      Hospital emergency room files

  • 50. 
    A nurse participating in a Nurse Managed Clinic wants to set up a diabetic teaching seminar.  The nurse understands that to meet the needs of the clients, the nurse must first:    
    • A. 

      Assess the clients’ functional abilities

    • B. 

      Ensure that the insurance documentation is up-to-date

    • C. 

      Discuss the focus of the seminar multidisciplinary team

    • D. 

      Include everyone who come into the clinic in the teaching sessions