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Nursing Comprehensive Exit exam 2024/2025 Questions With Completed & Verified Solutions.
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Nursing Comprehensive Exit examA nurse is caring for a client in the emergency department who complains of epigastric pain and
feeling lightheaded. The client has a blood pressure of 140/80 mmHg with a heart rate of 75/min
while supine and 110/65 mmHg sitting with a heart rate of 100/min. Which of the following tasks
should the nurse perform next? - ANS Anticipate administration of intravenous crystalloid
solution.
A nurse is caring for a 62-year-old client who has been diagnosed with emphysema. The nurse
understands that the client is at high-risk for pulmonary infection. Which of the following
conditions predisposes the client to infection? - ANS Pooling of respiratory secretions.
Which of the following methods of oxygen delivery should a nurse use to administer oxygen for
a client with a drop in oxygen saturation from 96% to 88% on room air after receiving morphine
to relieve pain after colon resection? (The client is resting but remains oriented and can be
easily aroused by verbal stimuli.) - ANS Nasal cannula
A nurse is caring for a woman who has undergone a radical mastectomy for breast cancer. She
tells the nurse, "I'm worried because my spouse won't touch me since my breast was removed."
Which of the following is the most appropriate response by the nurse? - ANS "How do you feel
about your mastectomy?"
A nurse is caring for a client who took an overdose of antidepressants and was discovered by
his spouse. What is the best response by the nurse when the spouse states, "If I hadn't come
home early from my business trip, my spouse might have died. I'm in a state of shock."? - ANS
"This is a very overwhelming situation for you. Can you tell me what you are feeling now?"
Which of the following pediatric clients would require prompt reporting to the authorities by the
nurse? - ANS A 4-year-old who fell from a swing set with 1 fracture of the ulna and 2 healed
fractures of the humerus on X-ray
A nurse is caring for a client who has a chest tube connected to a closed drainage system and
needs to be transported to the x-ray department. Which of the following actions should the
nurse take? - ANS Keep the drainage system below the level of the client's chest at all times.
Which of the following risk factors are part of the Braden Scale for Predicting Pressure Sore
Risk? (Select all that apply.) - ANS Friction and shear
Nutrition
The risk factors associated with the Braden Scale include sensory perception, moisture, activity,
mobility, nutrition, and friction and shear.
, A nurse is planning care for a client who has acute respiratory distress syndrome. Which of the
following interventions should the nurse include in the plan? - ANS Place in prone position
Respiratory cards following - ANS
A nurse is caring for a postoperative client who has a chest tube connected to suction and a
water seal drainage system. Which of the following indicates to the nurse that the chest tube is
functioning properly? - ANS Fluctuation of the fluid level within the water seal chamber
nurse is monitoring a client who has a chest tube in place connected to wall suction due to right
sided pneumothorax. The client complains of chest burning. Which of the following actions
should the nurse take? - ANS reposition the client
A nurse is caring for a client who has a three- chamber closed chest tube system. Which of the
following actions should the nurse take after noticing a rise in the water seal chamber with client
inspiration? - ANS continue to monitor the client
A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy.
The nurse notes slow, steady bubbling in the suction control chamber. Which of the following
actions should the nurse take? - ANS Continue to monitor client's respiratory status
A nurse is assessing a client who will undergo abdominal surgery in 2 hr. The client reports
being nervous about the surgery, last had food and fluids at 2330 the previous evening, and
signed the surgical consent 2 days ago. Which of the following is an appropriate nursing action
regarding these findings? - ANS Document the findings in the client's medical record.
A nurse in the post-anesthesia care unit is caring for a client who is postoperative following a
thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse
give highest priority to? - ANS Arterial blood gases.
The effectiveness of oxygenation is monitored using pulse oximetry and arterial blood gases.
A nurse is assessing a client following a bronchoscopy. Which of the following findings should
the nurse report to the provider? - ANS Bronchospasms
Bronchospasms can indicate the client is having difficulty maintaining a patent airway.
Blood-tinged sputum, a dry, nonproductive cough, and a sore throat are expected findings
following a bronchoscopy.
A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which
of the following actions should the nurse take? - ANS Position the client upright, leaning over
the bedside table.
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