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,Comprehensive - Predictor review 03/18/14
1. A nurse is assessing a client who has left-sided heart failure. Which of the following symptoms should the nurse
identify as the highest priority?
2. A nurse in the emergency department is assisting with the suturing of a laceration to the client’s face. Which of
the following actions should the nurse take?
__ Pour the sterile cleansing solution holding the bottle 10 cm (4 in.) above the sterile field
__ Pull the top flap of the suture tray towards the body when opening.
__ Place the bottle of local anesthetic 5 cm (2 in) inside the sterile field border.
__ Drop the suture package on to the sterile field from a distance of 30 cm (12 in).
3. A nurse is assessing a client 1 hr following delivery and notes that her uterus is boggy and….to the umbilicus.
Which of the following actions should the nurse take first?
__ Massage the fundus.
__ Assess lochia
__ Take vital signs
__ Give oxytocin (Pitocin) IV bolus.
4. (missing)
5.. A nurse is caring for a client who is 1 day postoperative following a hypophysectomy for removal of a pituitary
tumor. Which of the following findings requires further assessment by the nurse?
__ Urinary output greater than fluid intake
__ Report of dry mouth
__ Glasgow Coma Scale score of 15
__ Bloody drainage on the nasal dressing measuring 3 cm
6. A nurse in an emergency department is caring for a client who has multiple wounds due to a crash. Which of the
following interventions are appropriate? (Select all that apply).
__ Apply direct pressure to bleeding wounds.
__ Clean lacerations and abrasions with hydrogen peroxide.
__ Administer 650 mg aspirin PO as needed for pain.
__ Cover wounds with a sterile dressing
__ Determine date of last tetanus toxoid vaccination.
7. A nurse is planning care for four clients. Which of the following clients is the highest priority?
, __ A client who has frequent incontinence
__ A client who has dry, black eschar on the heel
__ A client who has a reddened skin area with blanching around the coccyx
__ A client who is wearing an arm cast and reports numb fingers
8. A nurse is assisting with mass casualty triage following an explosion at a local factory. Which of the clients
should the nurse identify as the priority?
__ A client who has massive head trauma
__ A client who has an open fracture of the lower extremity
__ A client who has full-thickness burns to the face and trunk
__ A client who has indication of hypovolemic shock
9. A nurse is planning care for a newly admitted adolescent client who has bacterial meningitis. Which of the
following instructions is appropriate for the nurse to include in the plan of care?
__ Assist the client to a supine position.
__ Recommend prophylactic acyclovir (Zovirax) for the client's family.
__ Initiate droplet precautions for the client.
__ Perform a Glasgow Coma Scale every 24 hr.
10. A nurse is caring for a client who is unconscious and has an advanced directive indicating no extraordinary
measures. The client's son wants everything possible done for his father. Which of the following is an
appropriate statement by the nurse?
__ "I will notify the health care provider of your wishes."
__ "Have you talked about this with your family?"
_X_ "We have to honor your father's wishes."
__ "Have you discussed this with your minister?"
11. A nurse is assessing a client brought to the hospital's psychiatric emergency services by a law enforcement
officer. The client has disorganized, incoherent speech with loose associations and religious content. The nurse
recognizes these signs and symptoms as being consistent with which of the following?
__ Alzheimer's disease
__ Depression
__ Substance intoxication
X Schizophrenia
12. A nurse is caring for a client who has a stool culture that is positive for Clostridium difficile (C. difficile) of the
following infection control precautions is appropriate?
__ Place the client in a negative pressure room.
, _X Place the client in a private room
__ Wear a face shield prior to entering the room.
__ Use an alcohol-based hand rub following client care.
13. A nurse is caring for a client who sprained his left ankle 12 hr. ago. Which of the following orders given
by the provider should the nurse clarify?
__ Elevate the affected extremity using two pillows.
__ Apply heat to the affected extremity for 45 min. on and then 45 min off.
__ Assess the affected extremity for sensation, movements and pulse every 4 hr.
__ Wrap the affected extremity with a compression dressing.
14. A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the
nurse plan to take?
__ Remove the disposable gown after leaving the toddler's room.
__ Place the toddler in a room with negative air pressure.
__ Use a designated stethoscope when caring for the toddler.
__ Wear an N95 respiratory mask while caring for the toddler.
15. A nurse is developing a discharge care plan for a client who has osteoporosis. To prevent injury, the nurse
should instruct the client to
__ avoid sitting in one position for prolonged periods.
__ avoid crossing the legs beyond the midline.
__ splint the affected area.
X_ perform weightbearing exercises.
16. A nurse receives a change-of-shift report on four clients. Based on the shift report information, which of the
following clients should the nurse plan to assess first?
__ A client who had a barium enema 2 days ago and reports constipation
__ A client who has anorexia and peripheral edema.
__ A client who has Addison's disease with a blood glucose level of 75 mg/dL
__ A client who had a hip arthroplasty reports and erythema in his calf.
17. A nurse working in a long-term care facility is caring for an older adult client who has dementia. The client is
often agitated and frequently wanders the halls. which of the following interventions should the nurse include in
the plan of care?
__ Maintain nutritional requirements by offering finger foods
__ Confront the client regarding unacceptable behavior.
__ Stimulate the client by leaving the television on throughout the day.
__ Give the client several choices when scheduling activities.
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