NURSING COMPREHENSIVE EXAM 4

50 Questions
Nursing Quizzes & Trivia
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Questions and Answers
  • 1. 
    A nurse working on an adult nursing unit is told to review the client census to determine which clients could be discharged if there are a large number of admissions from a newly declared disaster. The nurse interprets that the client with which of the following problems would not be able to be discharged, even if support was available at home?
    • A. 

      Laparoscopic cholecystectomy ( same day )

    • B. 

      Ongoing ventricular dysrhythmias while on procainamide ( Procan )

    • C. 

      Diabetes mellitus with blood glucose at 180 mg / dL

    • D. 

      Fractured hip pinned 5 days ago

  • 2. 
    A registered nurse ( RN ) is orienting a nursing assistant to the clinical nursing unit. The RN would intervene if the nursing assistant did which of the following during a routine handwashing procedure?   
    • A. 

      Kept hands lower than elbows

    • B. 

      Used 3 to 5 mL of soap from the dispenser

    • C. 

      Washed continuously for 10 to 15 seconds

    • D. 

      Dried from forearm down to fingers

  • 3. 
    • A. 

      Have three people available to assist

    • B. 

      Position the client in the center of the sling

    • C. 

      Have the client grasp the chains attaching the sling to the lift.

    • D. 

      Lower the client rapidly once positioned over the chair

  • 4. 
    An elderly client in a long-term care facility has a nursing diagnosis of risk for Injury related to confusion. The client's gait is stable. The nurse uses which of the following methods of restraint to prevent injury to the client?
    • A. 

      Vest restraint

    • B. 

      Waist restraint

    • C. 

      Chair with locking lap tray

    • D. 

      Alarm - activitating bracelet

  • 5. 
    Furosemide ( Lasix ) 40 mg PO has been prescribed for a client. A nurse administers Lasix 80 mg PO to the client at 10:00 A.M. Following discovery of the error, the nurse completes an incident report. Which of the following would the nurse document on this report?  
    • A. 

      Lasix 80 mg was given to the client instead of 40 mg.

    • B. 

      The wrong dose of medication was given to the client at 10:00 A.M

    • C. 

      I meant to give 40 mg of Lasix but I was rushed to get to another client who needed me and I gave the wrong dose.

    • D. 

      Lasix 80 mg administered at 10:00 A.M.

  • 6. 
    A registered nurse (RN) on the night shift assists a staff member in completing an incident report for a client who was found sitting on the floor. Following completion on the report, the RN avoids which action?         
    • A. 

      Documents in the nurses notes that an incident report was filed.

    • B. 

      Forwards the incident report to the Continuous Quality Improvement Department

    • C. 

      Asks the unit secretary to call the physician

    • D. 

      Notifies the nursing supervisor

  • 7. 
    A physician visits a client on the nursing unit. During the visit, the physician is called to another nursing unit to assess a client in extreme pain. The physician states to the nurse, “I'm in a hurry. Can you write the order to decrease the atenolol (Tenormin) to 25 mg daily?” Which of the following is the most appropriate nursing action?      
    • A. 

      Write the order as stated

    • B. 

      Call the nursing supervisor to write the order

    • C. 

      Ask the physician to return to the nursing unit to write the order

    • D. 

      Inform the client of the change of medication

  • 8. 
    A nurse is taking a temperature on a client using a glass thermometer. The nurse shakes down the thermometer and drops the thermometer on the floor. Which of the following actions will the nurse take?
    • A. 

      Carefully wipe up the spill, avoiding getting cut from the glass

    • B. 

      Use a mop and dustpan to clean up the spill, avoiding contact with the glass and mercury

    • C. 

      Notify the Environmental Services Department of the spill

    • D. 

      Call house keeping department to clean up the spill and broken glass

  • 9. 
    A nurse is called to a client’s room by another nurse. When the nurse arrives at the room, the nurse discovers that a fire has occurred in the client’s waste basket. The first nurse has removed the client from the room. What is the second nurse’s next action?     
    • A. 

      Evacuate the unit

    • B. 

      Extinguish the fire

    • C. 

      Confine the fire

    • D. 

      Activate the fire alarm

  • 10. 
    A nurse enters a client’s room and finds the client lying on the floor. Following assessment of the client, the nurse calls the nursing supervisor and the physician to inform them of the occurrence. The nursing supervisor instructs the nurse to complete an incident report. The nurse understands that incident reports allow the analysis of adverse client events by:         
    • A. 

      Evaluating quality care and the potential risks for injury to the client

    • B. 

      Determining the effectiveness of nursing interventions in relation to outcomes

    • C. 

      Providing a method of reporting injuries to local, state, and federal agencies

    • D. 

      Providing clients with necessary stabilizing treatments

  • 11. 
    A nurse observes that the client received pain medication 1 hour ago from another nurse, but that the client still has severe pain. The nurse has previously observed this same occurrence. The nurse practice act requires the observing nurse to do which of the following?
    • A. 

      Talk with the nurse who gave the medication

    • B. 

      Report the information to a nursing supervisor

    • C. 

      Call the impaired nurse organization

    • D. 

      Report the information to the police

  • 12. 
    A nurse lawyer provides an education session to the nursing staff regarding client rights. A staff nurse asks the lawyer to describe an example that might relate to invasion of client privacy. Which of the following indicates a violation of this right?
    • A. 

      Taking photographs of the client without consent

    • B. 

      Telling the client that he or she cannot leave the hospital

    • C. 

      Threatening to place a client in restraints

    • D. 

      Performing a surgical procedure without consent

  • 13. 
    A nurse witnesses an automobile accident and provides care to the open wound of a young child at the scene of the accident. The family is extremely grateful and insists that the nurse accept monetary compensation for the care provided to the child. Because of the family insistence, the nurse accepts the compensation to avoid offending the family. The child develops an infection and sepsis and is hospitalized. The family files suit against the nurse who provided care to the child at the scene of the accident. Which of the following is accurate regarding the nurse’s immunity from the suit? 
    • A. 

      The Good Samaritan Law will protect the nurse.

    • B. 

      The Good Samaritan Law will protect the nurse if the care given at the scene was not negligent

    • C. 

      The Good Samaritan Law will not provide immunity from suit if the nurse accepted compensation for the care provided.

    • D. 

      The Good Samaritan Law protects lay persons and not professional health care providers

  • 14. 
    A client brought to the emergency room after a serious accident is unconscious and bleeding profusely. Surgery is required immediately in order to save the client’s life. In regard to informed consent for the surgical procedure, which of the following is the best nursing action?  
    • A. 

      Try to obtain the spouse’s telephone number and call the spouse to obtain telephone consent before the surgical procedure

    • B. 

      Transport the client to the operating room immediately as required by the physician without obtaining an informed consent

    • C. 

      Ask the friend that accompanied the client to the emergency room to sign the consent form

    • D. 

      Call the nursing supervisor to initiate a court order for the surgical procedure

  • 15. 
    A home health care nurse arrives at a client’s home for the scheduled home visit. The client’s lawyer is present and the client is preparing a living will. The living will requires that the client’s signature be witnessed, and the client asks the nurse to witness the signature. Which of the following is the most appropriate nursing action?   
    • A. 

      Sign the will as a witness to signature only

    • B. 

      Sign the will, clearly identifying credentials and employment agency

    • C. 

      Decline to sign the will

    • D. 

      Call the home health care office and notify the supervisor that the will is being witnessed

  • 16. 
    An elderly woman is brought to the emergency room. On physical assessment, the nurse noted old and new ecchymotic areas on both arms and buttocks. The nurse asks the client on how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her daughter frequently hits her if she gets in the way. Which of the following is the most appropriate nursing response?  
    • A. 

      "I promise I will not tell anyone but let’s see what we can do about this."

    • B. 

      "I have a legal obligation to report this type of abuse."

    • C. 

      "Lets talk about ways that will prevent your daughter from hitting you."

    • D. 

      "This should not be happening, and if it happens again you must call the emergency department."

  • 17. 
    A client is brought to the emergency room by the ambulance team following collapse at home. Cardiopulmonary resuscitation is attempted but unsuccessful. The wife of the client tells the nurse that the client is an organ donor and that the eyes are to be donated. Which of the following is the most appropriate nursing action?       
    • A. 

      Elevate the head of the bed of the deceased and place dry sterile dressing over the eyes

    • B. 

      Call the National Donor Association to confirm that the client is a donor

    • C. 

      Close the deceased client’s eyes and place wet saline gauze pads and an ice pack on the eyes

    • D. 

      Ask the wife to obtain the legal documents regarding organ donation from the lawyer.

  • 18. 
    A client tells the home health care nurse of the decision to refuse external cardiac massage. Which of the following is the most appropriate initial nursing action? 
    • A. 

      Notify the physician of the client’s request

    • B. 

      Document the client’s request in the home health nursing care plan

    • C. 

      Conduct a client conference with the home health care staff to share the client’s request

    • D. 

      Discuss the client’s request with the family

  • 19. 
    A nurse is caring for a client with severe cardiac disease. While caring for the client, the client states to the nurse, “If anything should happen to me, please make sure that the doctors do not try to push on my chest and revive me.” The most appropriate nursing action is to:
    • A. 

      Tell the client that this procedure cannot legally be refused by a client if the doctor feels that it is necessary to save the client’s life

    • B. 

      Tell the client that it is necessary to notify the physician of the client’s request

    • C. 

      Tell the client that the family must agree with the request

    • D. 

      Plan a client conference with the nursing staff to share the client’s request

  • 20. 
    A nursing instructor is discussing professional liability insurance to the senior class of nursing students. The instructor most appropriately advises the students who will be graduating in two months:        
    • A. 

      To obtain their own malpractice insurance

    • B. 

      That malpractice insurance is not required and is expensive

    • C. 

      To discuss liability insurance with the employment agency

    • D. 

      That most lawsuits are filed against physicians

  • 21. 
    • A. 

      Refuse to float

    • B. 

      Call the nurse educator

    • C. 

      Report to the unit and identify tasks that can be safely performed

    • D. 

      Call the nursing supervisor

  • 22. 
    A nurse is planning care for an infant with a diagnosis of encephalocele located in the occipital area.  Which of the following items would the nurse use to assist in positioning the child to avoid pressure on the encephalocele?
    • A. 

      Sheepskin

    • B. 

      Foam hal-donut

    • C. 

      Feather pillow

    • D. 

      Sandbag

  • 23. 
    A nurse is planning care for an infant who has pyloric stenosis. In order to most effectively meet the infant’s preoperative needs, the nurse includes which of the following in the plan of care?
    • A. 

      Monitor the IV infusion, intake and output, and weight

    • B. 

      Provide small, frequent feedings of glucose, water, and electrolytes

    • C. 

      Administer enemas until returns are clear

    • D. 

      Provide the mother privacy to breastfeed every 2 hours

  • 24. 
    A nurse is planning care for a child with an infections and communicable disease.  The nurse determines that the primary goals is that the:
    • A. 

      Child will experience only minor complications

    • B. 

      Child will not spread the infection to others

    • C. 

      Public health department will be notified

    • D. 

      Child will experience mild discomfort

  • 25. 
    A nurse is performing an assessment of a child who is to receive a measles, mumps, and rubella (MMR) vaccine.  The nurse notes that the child is allergic to eggs.  Which of the following would be the nurse anticipate to be prescribed for this child?
    • A. 

      Administration of diphenhydramine (Benadryl) and acetaminophen (Tylenol) prior to the administration of the MMR vaccine

    • B. 

      Administration of a killed measles vaccine

    • C. 

      Eliminating this vaccine from the immunization schedule

    • D. 

      Administration of epinephrine (Adrenalin) prior to the administration of the MMR

  • 26. 
    • A. 

      File charges against the mother and father of the child

    • B. 

      Report the case to legal authorities

    • C. 

      Ask the mother to identify the individual who is physically abusing the child

    • D. 

      Tell the child that he will need to go to a foster home until the situation is straightened out

  • 27. 
    A nurse is obtaining a health history for an adolescent. Which statement by the adolescent indicates a need for follow-up assessment and intervention?
    • A. 

      I find myself very moody-happy one minute and crying the next.

    • B. 

      I can’t seem to wake up in the morning. I would sleep until noon if I could.

    • C. 

      I don’t eat anything with fat in it, and I’ve lost 8 pounds in 2 weeks.

    • D. 

      When I get stressed out about school, I just like to be alone.

  • 28. 
    • A. 

      Document the findings

    • B. 

      Continue to monitor for posturing of the child

    • C. 

      Attempt to flex the child’s lower extremities

    • D. 

      Notify the physician

  • 29. 
    A nurse is developing a plan of care for a newborn infant diagnosed with bilateral club feet.  The nurse includes instructions in the plan to tell the parents that:
    • A. 

      Genetic testing is wise for future pregnancies, since other children born to this couple may also be affected.

    • B. 

      If casting is needed, it will begin at birth and continue for 12 weeks; then the condition will be reevaluated.

    • C. 

      Surgery performed immediately after birth has been found to be most effective in achieving a complete recovery.

    • D. 

      The regimen of manipulation and casing is effective in all cases of bilateral club feet.

  • 30. 
    A nurse is developing a plan of care for a child returning from the operating room after a tonsillectomy.  The nurse avoids placing which intervention in the plan of care?    
    • A. 

      Offer clear, cool liquids when the child is awake

    • B. 

      Eliminate milk or milk products from the diet

    • C. 

      Monitor for bleeding from the surgical site

    • D. 

      Suction whenever necessary

  • 31. 
    A nurse is caring for an infant with laryngomalacia (Congenital) laryngeal stridor. In which of the following positions would the nurse place the infant to decrease the incidence of stridor?
    • A. 

      Supine

    • B. 

      Supine with the neck flexed

    • C. 

      Prone

    • D. 

      Prone with the neck hyperextended

  • 32. 
    • A. 

      Decreased red blood cell count

    • B. 

      Decreased bilirubin count

    • C. 

      Elevated blood glucose level

    • D. 

      Decreased white blood cell count

  • 33. 
    A nurse is caring for an infant after pyloromyotomy performed to treat hypertrophic pyloric stenosis. The nurse places the infant in which position following surgery?
    • A. 

      Flat on the nonoperative side

    • B. 

      Flat on the operative side

    • C. 

      Prone with the head of the bed elevated

    • D. 

      Supine with the head of the bed elevated

  • 34. 
    • A. 

      Encourage the child to fear the abuser

    • B. 

      Provide a care environment that allows for the development of trust

    • C. 

      Teach the child to make wise choice when confronted with an abusive situation

    • D. 

      Have the child point out the abuser if they should visit while the child is hospitalized

  • 35. 
    A nurse is caring for a hospitalized child with a diagnosis of rheumatic fever (RF), and the child has developed carditis.  The mother asks the nurse to explain the meaning of carditis.  The nurse plans to respond, knowing that which of the following most appropriately describes this complication of RF?
    • A. 

      Tender, painful joints, especially in the elbows, knees, ankles, and wrists

    • B. 

      Inflammation of all part of the heart, primarily the mitral vale

    • C. 

      Involuntary movements affecting the legs, arms, and face

    • D. 

      Red skin lesions start as flat or slightly raised macules, usually over the trunk and spread peripherally

  • 36. 
    A nurse is caring for a child with renal disease and is analyzing the laboratory results. The nurse notes a sodium level of 148 mEq/L.  On the basis of this finding which clinical manifestation would the nurse expect to note in the child?
    • A. 

      Increased heart rate

    • B. 

      Cold clammy skin

    • C. 

      Dry sticky mucous membranes

    • D. 

      Lethargy

  • 37. 
    A client appears very anxious, with respirations that are shallow and very rapid (40 per minute). The client complains of feeling dizzy and light-headed and having tingling sensations of the fingertips and around the lips. The nurse should recognize that the client's complaints are probably related to: 
    • A. 

      Eupnea

    • B. 

      Hyperventilation

    • C. 

      Kussmaul's respirations

    • D. 

      Carbon dioxide intoxication

  • 38. 
    A client arrives at the emergency room after being bitten by a stray dog. The bite involved tearing of skin and deep soft tissue injury. The client says the dog was foaming at the mouth and afterward ran away. The first nursing action is to: 
    • A. 

      Ask the client about horse serum allergy

    • B. 

      Notify the police department to capture the dog

    • C. 

      Assess the client's injury, vital signs, and past history

    • D. 

      Inoculate the client with human rabies immune globulin

  • 39. 
    A client comes to the clinic after being bitten by a raccoon in the woods in an area where rabies is endemic. The nurse recalls that rabies is: 
    • A. 

      An acute bacterial infection characterized by encephalopathy and opisthotonos

    • B. 

      An acute bacterial septicemia that results in convulsions and a morbid fear of water

    • C. 

      A nonspecific immunoresponse to organisms deposited under the skin by an animal bite

    • D. 

      An acute viral infection, characterized by convulsions and difficult swallowing, that affects the nervous system

  • 40. 
    A client complains of urinary problems. Cholinergic medications are prescribed. The nurse is aware that this type of medication is prescribed to prevent: 
    • A. 

      Kidney stones

    • B. 

      A flaccid bladder

    • C. 

      A spastic bladder

    • D. 

      Urinary tract infections

  • 41. 
    A client has a chest tube for pneumothorax. The nurse finds the client in respiratory difficulty with the chest tube separated from the drainage system. The nurse should: 
    • A. 

      Obtain a new sterile drainage system

    • B. 

      Clamp the drainage tubing with two clamps

    • C. 

      Reconnect the client's tube to the drainage system

    • D. 

      Place the client in the high-Fowler's position immediately

  • 42. 
    A client has a history of progressive carotid and cerebral atherosclerosis and transient ischemic attacks (TIAs). The nurse understands that TIAs are: 
    • A. 

      Temporary episodes of neurologic dysfunction

    • B. 

      Transient attacks caused by multiple small emboli

    • C. 

      Periods of alternating exacerbations and remissions

    • D. 

      Ischemic attacks that result in progressive neurologic deterioration

  • 43. 
    A client has a permanent sigmoid colostomy because of cancer. The physician orders daily colostomy irrigations. The nurse should explain to the client that the primary purpose of these irrigations is to:           
    • A. 

      Prevent straining at passage of stool

    • B. 

      Establish a regular elimination schedule

    • C. 

      Decrease the amount of flatus in the bowel

    • D. 

      Limit the amount of fluid lost from the intestine

  • 44. 
    A client has a Swan-Ganz catheter inserted for monitoring cardiovascular status. With the Swan-Ganz catheter the most accurate measurement of the client's left ventricular pressure would be the: 
    • A. 

      Right atrial pressure

    • B. 

      Cardiac output by thermodilution

    • C. 

      Pulmonary artery diastolic pressure

    • D. 

      Pulmonary capillary wedge pressure

  • 45. 
    A client has a tentative diagnosis of primary biliary cirrhosis. Symptoms include jaundice, ascites, and peripheral edema. When performing the physical assessment, the nurse would expect to observe the skin change known as: 
    • A. 

      Vitiligo

    • B. 

      Hirsutism

    • C. 

      Melenosis

    • D. 

      Telangiectasis

  • 46. 
    A client has a tumor of the cerebellum. In view of the functions of this structure, the nurse should expect to observe an: 
    • A. 

      Unconscious state

    • B. 

      Inability to execute voluntary movements

    • C. 

      Absence of the knee-jerk and other reflexes

    • D. 

      Inability to execute smooth, precise movements

  • 47. 
    A client has cholelithiasis with possible obstruction of the common bile duct. Before the scheduled cholecystectomy, nutritional deficiencies and excesses should be corrected. A nutritional assessment should be conducted to determine whether the client: 
    • A. 

      Is deficient in vitamins A, D, and K

    • B. 

      Eats adequate amounts of dietary fiber

    • C. 

      Consumes excessive amounts of protein

    • D. 

      Has excessive levels of potassium and folic acid

  • 48. 
    A client has decided to become a total vegetarian (vegan) and wishes to plan a diet to ensure adequate protein quality. To provide guidance, the nurse should instruct this client to: 
    • A. 

      Add milk to grains to provide complete proteins

    • B. 

      Use eggs with plant foods to provide essential amino acids

    • C. 

      Plan a careful mixture of plant proteins to provide a balance of amino acids

    • D. 

      Add cheese to grains and beans to increase the quality of protein consumed

  • 49. 
    A client has emergency surgery for a ruptured appendix. After assessing that the client is manifesting symptoms of shock the nurse should: 
    • A. 

      Prepare for a blood transfusion

    • B. 

      Notify the physician immediately

    • C. 

      Elevate the head of the bed 30 degrees

    • D. 

      Administer the oxygen prescribed postoperatively

  • 50. 
    A client has just been diagnosed with multiple sclerosis. The client is obviously upset with the diagnosis and asks, "Am I going to die?" The nurse's best response would be: 
    • A. 

      "Most individuals with your disease live a normal life span"

    • B. 

      "Is your family here? I would like to explain your disease to all of you"

    • C. 

      "The prognosis is variable; most individuals experience remissions and exacerbations"

    • D. 

      "Why don't you speak with your physician who can give you more details about your disease"