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Comprehensive Practice B W/Rationales
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Comprehensive Practice B W/Rationales
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ComprehensivePractice
B
W/Rationales
🥶
A
nurse
is
reinforcing
teaching
with
a
client
who
has
type
2
diabetes
mellitus
and
reports
waking
during
the
night
with
tremors
and
anxiety.
Which
of
the
following
information
should
the
nurse
include?
A.
Limit
carbohydrates
early
in
the
day.
B.
Practice
relaxation
techniques.
C.
Eat
a
bedtime
snack.
D.
Increase
daily
exercise.
Eat
a
bedtime
snack
*The
symptoms
described
by
the
client
indicate
hypoglycemia.
Eating
a
snack
at
bedtime
will
help
prevent
hypoglycemic
episodes
during
the
night.
A
nurse
is
assisting
with
the
admission
of
a
client
who
has
a
latex
allergy.
The
nurse
should
identify
that
which
of
the
following
supplies
has
the
potential
to
contain
latex?
A.
Indwelling
urinary
catheter
B.
Paper
tape
C.
Nitrile
gloves
D.
Gauze
dressings
Indwelling
urinary
catheter
*The
nurse
should
identify
that
most
indwelling
urinary
catheters
are
made
of
rubber,
which
is
a
form
of
latex.
A
rubber
indwelling
urinary
catheter
should
not
be
used
for
a
client
who
has
a
latex
allergy.
The
nurse
should
obtain
an
indwelling
urinary
catheter
made
of
silicone
for
a
client
who
has
a
latex
allergy.
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A
nurse
is
caring
for
a
client
who
has
an
altered
mental
status
and
has
become
aggressive.
Which
of
the
following
prescriptions
should
the
nurse
clarify
with
the
provider
prior
to
administration?
A.
Haloperidol
B.
Lorazepam
C.
Zolpidem
D.
Alprazolam
Zolpidem
*Zolpidem
is
a
sedative-hypnotic
medication
used
to
treat
insomnia.
It
is
not
indicated
for
treatment
of
confusion
and
aggressive
behavior.
Zolpidem
can
cause
agitation
and
should
be
used
with
caution
for
clients
who
have
a
history
of
mental
illness.
Therefore,
the
nurse
should
clarify
this
prescription
with
the
provider
prior
to
administration.
A
nurse
is
reviewing
the
laboratory
results
for
a
client
who
is
at
29
weeks
of
gestation.
For
which
of
the
following
results
should
the
nurse
notify
the
provider?
A.
Platelet
count
95,000
mm3
B.
BUN
15
mg/dL
C.
Hgb
11.3
g/dL
D.
WBC
count
10,000/mm3
Platelet
count
95,000
mm3
*The
nurse
should
recognize
that
this
platelet
count
is
below
the
expected
reference
range
for
a
client
who
is
pregnant
and
might
be
indicative
of
HELLP
syndrome.
Other
manifestations
of
HELLP
syndrome
include
malaise
and
epigastric
pain.
The
nurse
should
immediately
notify
the
provider
of
this
result.
A
nurse
notices
an
assistive
personnel
(AP)
taking
a
nap
in
the
break
during
meal
time.
The
nurse
also
notes
that
the
AP
is
drowsy
while
performing
routine
tasks.
Which
of
the
following
actions
should
the
nurse
take?
A.
Keep
a
record
of
the
AP's
behavior
over
a
period
of
time.
B.
Report
the
observations
about
the
AP
to
the
unit's
nurse
manager.
C.
Ask
another
unit
staff
member
if
they
have
observed
the
same
behavior.
D.
Determine
if
the
AP
is
having
problems
at
home.
Report
the
observations
about
the
AP
to
the
unit's
nurse
manager.
*The
nurse
should
report
their
observations
to
the
unit's
nurse
manager
because
they
have
a
duty
to
report
any
behavior
that
poses
a
risk
to
client
safety. A
nurse
in
a
long-term
care
facility
is
assisting
with
an
inservice
for
newly
hired
assistive
personnel
about
legal
issues
within
the
facility.
Which
of
the
following
should
the
nurse
include
as
an
example
of
assault?
A.
Telling
another
nurse
rumors
about
a
client
newly
admitted
to
the
unit
B.
Informing
a
client
that
the
nurse
is
going
to
administer
an
injection
even
though
the
client
refuses
C.
Telling
a
clergy
member
that
one
of
their
church
members
has
been
admitted
to
the
facility
without
the
client's
permission
D.
Placing
a
restraint
on
a
client
to
keep
them
in
bed
before
trying
alternative
measures
Informing
a
client
that
the
nurse
is
going
to
administer
an
injection
even
though
the
client
refuses
*This
is
an
example
of
assault,
which
is
the
threat
of
unlawful
touching
of
an
individual.
The
nurse
should
respect
the
client's
right
to
refuse
treatment
and
not
administer
an
injection
against
the
client's
wishes.
A
nurse
is
collecting
data
from
a
client
who
has
type
2
diabetes
mellitus
and
is
concerned
about
weight
gain
during
pregnancy.
Which
of
the
following
responses
should
the
nurse
make?
A.
"Your
weight
gain
should
be
the
same
as
for
someone
without
diabetes."
B.
"Weight
gain
should
be
2
pounds
during
the
first
trimester
and
2
pounds
per
week
thereafter."
C.
"Weight
reduction
during
pregnancy
is
often
necessary
for
clients
who
have
diabetes."
D.
"Your
weight
gain
should
average
between
10
and
15
pounds."
"Your
weight
gain
should
be
the
same
as
for
someone
without
diabetes."
*A
client
who
is
pregnant
and
has
diabetes
mellitus
should
gain
the
same
amount
of
weight
as
a
client
without
diabetes
mellitus.
A
nurse
is
collecting
data
from
a
client
who
has
multiple
sclerosis.
Which
of
the
following
findings
should
the
nurse
expect?
A.
Ptosis
B.
Photophobia
C.
Ataxia
D.
Bradykinesia
Ataxia
*The
nurse
should
expect
a
client
who
has
multiple
sclerosis
to
manifest
ataxia,
which
is
a
lack
of
coordination
and
movement.
Other
manifestations
include
fatigue,
impaired
memory,
diplopia,
and
bowel
and
bladder
incontinence. A
nurse
is
caring
for
a
client
who
requests
information
about
advance
directives.
Which
of
the
following
responses
should
the
nurse
make?
A.
"Advance
directives
provide
education
on
palliative
care
issues."
B.
"Advance
directives
require
the
provider's
approval
before
changes
can
be
implemented."
C.
"Advance
directives
are
written
instructions
regarding
end-of-life
care."
D.
"Advance
directives
help
determine
legal
competency."
"Advance
directives
are
written
instructions
regarding
end-of-life
care."
*The
nurse
should
inform
the
client
that
advance
directives
allow
the
client
to
make
decisions
and
provide
written
instructions
regarding
end-of-life
care.
These
directives
take
effect
if
the
client
is
unable
to
make
their
own
health
care
decisions.
A
nurse
has
administered
medications
to
a
group
of
clients.
For
which
of
the
following
client
situations
should
the
nurse
complete
an
incident
report?
A.
The
nurse
administered
enalapril
to
a
client
who
has
a
blood
pressure
of
162/90
mm
Hg
B.
A
client
who
received
morphine
for
postoperative
pain
becomes
somnolent
C.
The
nurse
administered
insuling
lispro
to
a
client
who
has
diabets
mellitus
and
is
NPO
D.
The
nurse
administered
heparin
to
a
client
who
has
an
aPTT
of
60
seconds
The
nurse
administered
insuling
lispro
to
a
client
who
has
diabets
mellitus
and
is
NPO
*Lispro
is
a
rapid-acting
insulin
given
with
or
just
after
meals
because
the
onset
of
action
is
15
to
30
min
after
administration.
A
client
who
is
NPO
will
not
receive
a
meal
and
can
have
a
potentially
serious
drop
in
blood
glucose
levels.
Therefore,
the
nurse
should
complete
an
incident
report
after
ensuring
the
safety
of
the
client
and
notifying
the
client's
provider.
A
nurse
is
preparing
to
administer
a
rectal
suppository
to
a
school-age
child.
Which
of
of
the
following
actions
should
the
nurse
plan
to
take?
A.
Use
one
finger
to
insert
the
suppository
past
the
anal
sphincters.
B.
Place
the
child
in
a
lithotomy
position.
C.
Cut
the
suppository
in
half
crosswise
prior
to
insertion.
D.
Don
sterile
gloves
prior
to
inserting
the
suppository.
Use
one
finger
to
insert
the
suppository
past
the
anal
sphincters.
*The
nurse
should
apply
clean
gloves
and
use
one
finger
to
gently
insert
the
suppository
past
both
anal
sphincters
to
ensure
that
the
child
does
not
expel
the
suppository
after
insertion.
A
nurse
is
checking
a
newborn's
vital
signs.
Which
of
the
following
methods
of
temperature
measurement
should
the
nurse
use?
A.
Rectal
B.
Axillary
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