Comprehensive (Latest UPDATES STUDY) Exam Reviews Questions and Verified Answers 100% Correct Grade A
Comprehensive
a. Ensure the state health department has been notified - -A home health nurse is caring
for a child who has lyme disease. Which of the following is an appropriate action for ...
Comprehensive
a. Ensure the state health department has been notified - ✅✅-A home health nurse is caring
for a child who has lyme disease. Which of the following is an appropriate action for the nurse to
take
a. Ensure the state health department has been notified
b. Administer antitoxin
c. Educate the family to avoid sharing personal belongings
d. Assess for skin necrosis
- Provide frequent rest periods
- Restrict client sodium intake
- Advise client to avoid using soap and alcohol based lotions
✅✅
- Instruct the client to avoid blowing their nose forcefully
- Assess the client's lv of orientation - -A nurse is caring for a client who has been admitted
to the hospital. (NGN)
b. Evaluate functioning of the suction device - ✅✅ -A nurse is caring for a client who has a
vented NG tube set to low intermittent suction and has vomited. Which of the following actions
should the nurse perform first?
a. Administered an antiemetic medication
b. Evaluate functioning of the suction device
c. Provide oral hygrine care
d. Replace the NG tube
c. Remove the device from the room - ✅✅ -While performing a routine assessment, a nurse
notices fraying on the electrical cord of a client's continuous passive motion device. Which of the
following actions should the nurse take first
a. Initiate a requisition for a replacement CPM device
b. Report the defect to the equipment maintenance staff
c. Remove the device from the room
d. Ensure the device inspection sticker is current
a. Remove the cap and place it sterile-side up on a clean surface - ✅✅ -A nurse is setting up a
sterile field to perform would irrigation for a client. Which of the following actions should the
nurse take when pouring the sterile solution
a. Remove the cap and place it sterile-side up on a clean surface
b. Pace sterile gauze over areas of spilled
c. Hold the bottle in the center of the sterile field when pouring the solution
d. Hold the irrigation solution bottle with the label facing away from the palm of the hand
,a. Wear loose-fitting underwear - ✅✅ -A nurse is creating a plan of care for a female client who
has recurrent urinary tract infections. Which of the following interventions should the nurse
include in the plan
a. Wear loose-fitting underwear
b. Take a bubble bath after intercourse
c. Drink four 240 ml (8 oz) glasses of water each day
d. Void every 5-6 hr during the day
Tachypnea of the newborn and hypoglycemia. - ✅✅-A nurse is caring for a newborn. Fiil in the
blank (NGN)
The client at risk for developing _____ and _____
a. Hypoglycemia
b. Bronchopulmonary dysplasia
c. Transient tachypnea of the newborn
d. Tachycardia
b. Sunken fontanels and dry mucous membranes - ✅✅ -A nurse is caring for an infant who has
gastroenteritis. Which of the following assessment findings should the nurse report to the
provider?
a. Pale and a 24-hr fluid deficit of 30 mL
b. Sunken fontanels and dry mucous membranes
c. Decrease appetite and irritability
d. Temperature 38 C and pulse rate of 124/min
a. Hypertension - ✅✅ -A nurse is conducting health promotion education regarding
contraindication to combination oral contraceptive use to a group of women. Which of the
following conditions should the nurse includes in the teaching?
a. Hypertension
b. Fibromyalgia
c. Renal calculi
d. Fibrocystic breast diseases
b. I know it will be a couple of weeks before the medication helps me feel better - ✅✅ -A nurse
is providing teaching to a client who has a depressive disorder and a new prescription for
amitriptyline. Which of the following statements by the client indicates an understanding of the
teaching?
a. I can continue to take St. john wort while taking this medication
b. I know it will be a couple of weeks before the medication helps me feel better
,c. I expect this medication to raise my blood pressure
d. I should take this medication on an empty stomach
c. Align a trochanter wedge between the client's legs - ✅✅ -A nurse is caring for a client who is
immobile. Which of the following interventions is appropriate to prevent contracture
a. Position a pillow under the client's knee
b. Place a towel roll under the client's neck
c. Align a trochanter wedge between the client's legs
d. Apply an orthotic to the client's foot
d. Obtain a urine specimen for culture and sensitivity - ✅✅ -A nurse is assessing a client who
is post-op following abdominal surgery and has an indwelling urinary catheter that is draining
dark yellow urine at 25 ml/h. Which of the following should the nurse anticipate?
a. Initiate continuous bladder irrigation
b. Administer fluid bolus
c. Clamp the catheter tubing for 30 min
d. Obtain a urine specimen for culture and sensitivity
c. INR -✅✅ -A nurse is reporting a client's laboratory tests to the provider to obtain a
prescription for the client's daily warfarin. Which of the following should the nurse report to
obtain the prescription for warfarin
a. Fibrinogen lv
b. aPTT
c. INR
d. Platelet count
b. Shuffling gait - ✅✅
-A nurse is assessing a client ho is taking haloperidol and is
experiencing pseudo parkinsonism. Which of the following is the signs of pseudo parkinsonism
a. Serpentine limb movement
b. Shuffling gait
c. Nonreactive pupils
d. Smacking lips
d. Have interdisciplinary team meetings for the client on a regular basis - ✅✅ -A nurse care for
client with expressive aphasia and right hemiparesis after a stroke. What is the best way to
promotes communication among staff caring for the client?
a. Posting swallow precautions at the head of client's bed
b. Noting changes in the treatment plan in the client's medical record
c. Recording the clients progress in the nurse's note
, d. Have interdisciplinary team meetings for the client on a regular basis
a. Banana slices - ✅✅-A nurse is caring for a 2 yo toddler. Which food choice should the
nurse recommended to promote independence in eating?
a. Banana slices
b. Grapes
c. Hot dog
d. Popcorn
✅✅
c. Determine the medical needs of incoming clients through the emergency department -
-A nurse on med-surge unit got notified that a mass casualty event has occurred. Which
action should the nurse take?
a. Act as a liaison between the facility and media
b. Recommend to the provider specific acute care clients for discharge
c. Determine the medical needs of incoming clients through the emergency department
d. Call in additional med-surge unit nursing care staff
c. A client who has just given a glass of orange juice for a low blood glucose lv - ✅✅-A nurse
has received report for 4 clients. Who should the nurse see first?
a. A client who is scheduled for a procedure in 1 hr
b. A client who received a pain med 30 min ago fir post-op pain
c. A client who has just given a glass of orange juice for a low blood glucose lv
d. A client who has 100 ml of fluid remain in his IV bag
b. Hold client's eyes shut for a few seconds - ✅✅ -A nurse is performing postmortem care prior
to the client's family visit. Which action should the nurse take?
a. Cross patient's arms across their chest
b. Hold client's eyes shut for a few seconds
c. Place client in a high fowler's position
d. Removed the client's dentures from their mouth
a. What are the voices telling you? - ✅✅ -A nurse admitting a schizophrenic client. Client state:
"I'm hearing voices". Which responses is the priority for the nurse to state?
a. What are the voices telling you?
b. I realize the voices are real to you, but I don't hear anything
c. Have you taken your med today?
d. How long have you been hearing the voices?
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