EXAM MODE: Comprehensive Exam
QUESTION AND 100%CORRECT ANSWERS
The health care provider prescribes 1000 mL of a D5W solution to infuse over 8 hours for a
client who has had an appendectomy. The IV tubing being used delivers 15 gtt/mL. The
nurse should set the flow rate at how many gtt/min? _____ /(If rounding is necessary,
round to the nearest whole drop.)/ - Correct Answers -1000 mL D5W/8 hours = 125 mL/hr
× 15 gtt/60 = 31.2 gtt/min. or 31 gtt/min.
31 gtt/min
The nurse is assisting a father to change the diaper of his 2-day-old infant. The father notices
several bluish-black pigmented areas on the infant's buttocks and asks the nurse, "What did you
do to my baby?" Which response is best for the nurse to provide?
A. "What makes you think we did anything to your baby?"
B. "Are you or any of your blood relatives of Asian descent?"
C. "Those are stork bites and will go away in about 2 years."
D. "Those are Mongolian spots and will gradually fade in 1 or 2 years." - Correct Answers -D.
"Those are Mongolian spots and will gradually fade in 1 or 2 years."
Rationale: Mongolian spots are areas of bluish-black or gray-blue pigmentation seen primarily
on the dorsal area and buttocks of infants of Asian or African descent or dark-skinned babies.
Option A is a defensive answer. Although Mongolian spots occur more frequently in those of
Asian and African descent, option B does not respond to the father's concern. Telangiectatic
nevi, frequently referred to as stork bites, appear reddish-purple or red and are usually on the
face or head and neck area.
A client has been on a mechanical ventilator for several days. What assessment data should the
nurse use to document and record this client's respirations?
A. The respiratory settings on the ventilator
,B. Only the client's spontaneous respirations
C. The ventilator-assisted respirations minus the client's independent breaths
D. The ventilator setting for respiratory rate and the client-initiated respirations - Correct
Answers -D. The ventilator setting for respiratory rate and the client-initiated respirations
Rationale: The nurse should count the client's respirations and document both the respiratory
rate set by the ventilator and the client's independent respiratory rate. Never rely strictly on
option A. Although the client's spontaneous breaths will be shallow and machine-assisted
breaths will be deep, it is important to record machine-assisted breaths as well as the client's
spontaneous breaths to get an overall respiratory picture of the client.
The client with which fasting plasma glucose level needs the most immediate action by the
nurse?
A. 50 mg/dL
B. 80 mg/dL
C. 110 mg/dL
D. 140 mg/dL - Correct Answers -A. 50 mg/dL
Rationale: The normal fasting plasma glucose level ranges from 70 to 105 mg/dL. A client with a
low level, such as 50 mg/dL, requires the most immediate intervention to prevent loss of
consciousness. Normal (such as 80 mg/dL) and slightly elevated levels, such as 110 or 140
mg/dL, do not require immediate intervention.
A child with nephrotic syndrome is receiving prednisone. Which choice of breakfast foods at a
fast-food restaurant indicates that the mother understands the dietary guidelines necessary for
her child?
A. French toast sticks and orange juice
,B. Sausage egg muffin and grape juice
C. Canadian bacon slices and hot chocolate
D. Toasted oat cereal and low-fat milk - Correct Answers -D. Toasted oat cereal and low-fat milk
Rationale: A child receiving a corticosteroid for nephrotic syndrome should follow a low-sodium,
low-fat, and low-sugar diet. Based on these guidelines, the best breakfast choice is option D.
Option A is high in fat and sugar. Options B and C are high in fat and sodium.
A nurse who has recently completed orientation is beginning work in the labor and delivery unit
for the first time. When making assignments, which client should the charge nurse assign to this
new nurse?
A. A primigravida who is 8 cm dilated after 14 hours of labor
B. A client scheduled for a repeat cesarean birth at 38 weeks' gestation
C. A client being induced for fetal demise at 20 weeks' gestation
D. A multiparous client who is dilated 5 cm and 50% effaced - Correct Answers -D. A multiparous
client who is dilated 5 cm and 50% effaced
Rationale: The new nurse should be assigned the least complicated client to gain experience
and confidence, as well as protect client safety. Of the clients available for assignment, option D
is progressing well and is the least complicated. Options A, B, and C have actual or potential
complications and should be assigned to a more experienced nurse.
A client with acquired immunodeficiency syndrome (AIDS) is hospitalized after a recent
discharge. Which nursing action is most important in reducing the client's stress associated with
repeated hospitalizations?
A. Allow the client to discuss the seriousness of the illness.
B. Ensure that the client is provided with information about medications.
, C. Encourage as much independence in decision-making as possible.
D. Include the client in planning the course of treatment. - Correct Answers -C. Encourage as
much independence in decision-making as possible.
Rationale: Hospitalization compromises an individual's sense of control and independence,
which contributes to stress, so allowing the client as much independence in decisions as
possible helps reduce stress experienced with repeated hospitalization. Options A, B, and D are
important components in stress reduction, but the isolation and dependence associated with
hospitalization alter the client's sense of control and affect the client's cognitive ability to
understand and participate in the hospitalized plan of care.
A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide PO and 40
mg of furosemide PO daily. Today, at a routine clinic visit, the client's serum potassium level is 4
mEq/L. What is the most likely cause of this client's potassium level?
A. The client is noncompliant with taking medications.
B. The client recently consumed large quantities of pears or nuts.
C. The client's renal function has affected the potassium level.
D. The client needs to be started on a potassium supplement. - Correct Answers -C. The client's
renal function has affected the potassium level.
Rationale: The client has a normalized potassium level despite diuretic use. The kidney
automatically secretes 90% of potassium consumed, but in chronic renal insufficiency (CRI), less
potassium is excreted than normal. Therefore, the two potassium-wasting drugs, a thiazide
diuretic and loop diuretic, are not likely to affect potassium levels. The normal potassium level is
3.5 to 5 mEq/L, and with a potassium level of 4 mEq/L, there is no reason to believe that the
client is noncompliant with his treatment. Pears and nuts do not affect the serum potassium
level. There is no need for a potassium supplement because the client's potassium level is
within the normal range.
QUESTION AND 100%CORRECT ANSWERS
The health care provider prescribes 1000 mL of a D5W solution to infuse over 8 hours for a
client who has had an appendectomy. The IV tubing being used delivers 15 gtt/mL. The
nurse should set the flow rate at how many gtt/min? _____ /(If rounding is necessary,
round to the nearest whole drop.)/ - Correct Answers -1000 mL D5W/8 hours = 125 mL/hr
× 15 gtt/60 = 31.2 gtt/min. or 31 gtt/min.
31 gtt/min
The nurse is assisting a father to change the diaper of his 2-day-old infant. The father notices
several bluish-black pigmented areas on the infant's buttocks and asks the nurse, "What did you
do to my baby?" Which response is best for the nurse to provide?
A. "What makes you think we did anything to your baby?"
B. "Are you or any of your blood relatives of Asian descent?"
C. "Those are stork bites and will go away in about 2 years."
D. "Those are Mongolian spots and will gradually fade in 1 or 2 years." - Correct Answers -D.
"Those are Mongolian spots and will gradually fade in 1 or 2 years."
Rationale: Mongolian spots are areas of bluish-black or gray-blue pigmentation seen primarily
on the dorsal area and buttocks of infants of Asian or African descent or dark-skinned babies.
Option A is a defensive answer. Although Mongolian spots occur more frequently in those of
Asian and African descent, option B does not respond to the father's concern. Telangiectatic
nevi, frequently referred to as stork bites, appear reddish-purple or red and are usually on the
face or head and neck area.
A client has been on a mechanical ventilator for several days. What assessment data should the
nurse use to document and record this client's respirations?
A. The respiratory settings on the ventilator
,B. Only the client's spontaneous respirations
C. The ventilator-assisted respirations minus the client's independent breaths
D. The ventilator setting for respiratory rate and the client-initiated respirations - Correct
Answers -D. The ventilator setting for respiratory rate and the client-initiated respirations
Rationale: The nurse should count the client's respirations and document both the respiratory
rate set by the ventilator and the client's independent respiratory rate. Never rely strictly on
option A. Although the client's spontaneous breaths will be shallow and machine-assisted
breaths will be deep, it is important to record machine-assisted breaths as well as the client's
spontaneous breaths to get an overall respiratory picture of the client.
The client with which fasting plasma glucose level needs the most immediate action by the
nurse?
A. 50 mg/dL
B. 80 mg/dL
C. 110 mg/dL
D. 140 mg/dL - Correct Answers -A. 50 mg/dL
Rationale: The normal fasting plasma glucose level ranges from 70 to 105 mg/dL. A client with a
low level, such as 50 mg/dL, requires the most immediate intervention to prevent loss of
consciousness. Normal (such as 80 mg/dL) and slightly elevated levels, such as 110 or 140
mg/dL, do not require immediate intervention.
A child with nephrotic syndrome is receiving prednisone. Which choice of breakfast foods at a
fast-food restaurant indicates that the mother understands the dietary guidelines necessary for
her child?
A. French toast sticks and orange juice
,B. Sausage egg muffin and grape juice
C. Canadian bacon slices and hot chocolate
D. Toasted oat cereal and low-fat milk - Correct Answers -D. Toasted oat cereal and low-fat milk
Rationale: A child receiving a corticosteroid for nephrotic syndrome should follow a low-sodium,
low-fat, and low-sugar diet. Based on these guidelines, the best breakfast choice is option D.
Option A is high in fat and sugar. Options B and C are high in fat and sodium.
A nurse who has recently completed orientation is beginning work in the labor and delivery unit
for the first time. When making assignments, which client should the charge nurse assign to this
new nurse?
A. A primigravida who is 8 cm dilated after 14 hours of labor
B. A client scheduled for a repeat cesarean birth at 38 weeks' gestation
C. A client being induced for fetal demise at 20 weeks' gestation
D. A multiparous client who is dilated 5 cm and 50% effaced - Correct Answers -D. A multiparous
client who is dilated 5 cm and 50% effaced
Rationale: The new nurse should be assigned the least complicated client to gain experience
and confidence, as well as protect client safety. Of the clients available for assignment, option D
is progressing well and is the least complicated. Options A, B, and C have actual or potential
complications and should be assigned to a more experienced nurse.
A client with acquired immunodeficiency syndrome (AIDS) is hospitalized after a recent
discharge. Which nursing action is most important in reducing the client's stress associated with
repeated hospitalizations?
A. Allow the client to discuss the seriousness of the illness.
B. Ensure that the client is provided with information about medications.
, C. Encourage as much independence in decision-making as possible.
D. Include the client in planning the course of treatment. - Correct Answers -C. Encourage as
much independence in decision-making as possible.
Rationale: Hospitalization compromises an individual's sense of control and independence,
which contributes to stress, so allowing the client as much independence in decisions as
possible helps reduce stress experienced with repeated hospitalization. Options A, B, and D are
important components in stress reduction, but the isolation and dependence associated with
hospitalization alter the client's sense of control and affect the client's cognitive ability to
understand and participate in the hospitalized plan of care.
A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide PO and 40
mg of furosemide PO daily. Today, at a routine clinic visit, the client's serum potassium level is 4
mEq/L. What is the most likely cause of this client's potassium level?
A. The client is noncompliant with taking medications.
B. The client recently consumed large quantities of pears or nuts.
C. The client's renal function has affected the potassium level.
D. The client needs to be started on a potassium supplement. - Correct Answers -C. The client's
renal function has affected the potassium level.
Rationale: The client has a normalized potassium level despite diuretic use. The kidney
automatically secretes 90% of potassium consumed, but in chronic renal insufficiency (CRI), less
potassium is excreted than normal. Therefore, the two potassium-wasting drugs, a thiazide
diuretic and loop diuretic, are not likely to affect potassium levels. The normal potassium level is
3.5 to 5 mEq/L, and with a potassium level of 4 mEq/L, there is no reason to believe that the
client is noncompliant with his treatment. Pears and nuts do not affect the serum potassium
level. There is no need for a potassium supplement because the client's potassium level is
within the normal range.
