NLE COMPREHENSIVE EXAMS
1. A pregnant woman who is at term is admitted to the birthing unit in active labor. The client
has only progressed from 2cm to 3 cm in 8 hours. She is diagnosed with
hypotonic dystocia and the physician ordered Oxytocin (Pitocin) to augment her contractions.
Which of the following is the most important aspect of nursing intervention at this time?
A. Timing and recording length of contractions.
B. Monitoring.
C. Preparing for an emergency cesarean birth.
D. Checking the perineum for bulging.
2. A client who hallucinates is not in touch with reality. It is important for the nurse to:
A. Isolate the client from other patients.
B. Maintain a safe environment.
C. Orient the client to time, place, and person.
D. Establish a trusting relationship.
3. The nurse is caring to a child client who has had a tonsillectomy. The child complains of
having dryness of the throat. Which of the following would the nurse give to the child?
A. Cola with ice
B. Yellow noncitrus Jello
C. Cool cherry Kool-Aid
D. A glass of milk
4. The physician ordered Phenylephrine (Neo-Synephrine) nasal spray to a 13-year-old client.
The nurse caring to the client provides instructions that the nasal spray must be used exactly
as directed to prevent the development of:
A. Increased nasal congestion.
B. Nasal polyps.
C. Bleeding tendencies.
D. Tinnitus and diplopia.
,5. A client with tuberculosis is to be admitted in the hospital. The nurse who will be assigned
to care for the client must institute appropriate precautions. The nurse should:
A. Place the client in a private room.
B. Wear an N 95 respirator when caring for the client.
C. Put on a gown every time when entering the room.
D. Don a surgical mask with a face shield when entering the room.
6. Which of the following is the most frequent cause of noncompliance to the medical
treatment of open-angle glaucoma?
A. The frequent nausea and vomiting accompanying use of miotic drug.
B. Loss of mobility due to severe driving restrictions.
C. Decreased light and near-vision accommodation due to miotic effects of pilocarpine.
D. The painful and insidious progression of this type of glaucoma.
7. In the morning shift, the nurse is making rounds in the nursing care units. The nurse enters
in a client’s room and notes that the client’s tube has become disconnected from the
Pleurovac. What would be the initial nursing action?
A. Apply pressure directly over the incision site.
B. Clamp the chest tube near the incision site.
C. Clamp the chest tube closer to the drainage system.
D. Reconnect the chest tube to the Pleurovac.
8. Which of the following complications during a breech birth the nurse needs to be alarmed?
A. Abruption placenta.
B. Caput succedaneum.
C. Pathological hyperbilirubinemia.
D. Umbilical cord prolapse.
9. The nurse is caring to a client diagnosed with severe depression. Which of the following
nursing approach is important in depression?
,A. Protect the client against harm to others.
B. Provide the client with motor outlets for aggressive, hostile feelings.
C. Reduce interpersonal contacts.
D. Deemphasizing preoccupation with elimination, nourishment, and sleep.
10. A 3-month-old client is in the pediatric unit. During assessment, the nurse is suspecting
that the baby may have hypothyroidism when mother states that her baby does not:
A. Sit up.
B. Pick up and hold a rattle.
C. Roll over.
D. Hold the head up.
11. The physician calls the nursing unit to leave an order. The senior nurse had conversation
with the other staff. The newly hired nurse answers the phone so that the senior nurses may
continue their conversation. The new nurse does not knowthe physician or the client to whom
the order pertains. The nurse should:
A. Ask the physician to call back after the nurse has read the hospital policy manual.
B. Take the telephone order.
C. Refuse to take the telephone order.
D. Ask the charge nurse or one of the other senior staff nurses to take the telephone order.
12. The staff nurse on the labor and delivery unit is assigned to care to a primigravida in
transition complicated by hypertension. A new pregnant woman in active labor is admitted in
the same unit. The nurse manager assigned the same nurse to the second client. The nurse
feels that the client with hypertension requires one-to-one care. What would be the initial
actionof the nurse?
A. Accept the new assignment and complete an incident report describing a shortage of
nursing staff.
B. Report the incident to the nursing supervisor and request to be floated.
C. Report the nursing assessment of the client in transitional labor to the nurse manager and
discuss misgivings about the new assignment.
D. Accept the new assignment and provide the best care.
, 13. A newborn infant with Down syndrome is to be discharged today. The nurse is preparing
to give the discharge teaching regarding the proper care at home. The nurse would anticipate
that the mother is probably at the:
A. 40 years of age.
B. 20 years of age.
C. 35 years of age.
D. 20 years of age.
14. The emergency department has shortage of staff. The nurse manager informs the staff
nurse in the critical care unit that she has to float to the emergency department. What should
the staff nurse expect under these conditions?
A. The float staff nurse will be informed of the situation before the shift begins.
B. The staff nurse will be able to negotiate the assignments in the emergency department.
C. Cross training will be available for the staff nurse.
D. Client assignments will be equally divided among the nurses.
15. The nurse is assigned to care for a child client admitted in the pediatrics unit. The client is
receiving digoxin. Which of the following questions will be asked by the nurse to the parents
of the child in order to assess the client’s risk for digoxin toxicity?
A. “Has he been exposed to any childhood communicable diseases in the past 2-3 weeks?”
B. “Has he been taking diuretics at home?”
C. “Do any of his brothers and sisters have history of cardiac problems?”
D. “Has he been going to school regularly?”
16. The nurse noticed that the signed consent form has an error. The form states, “Amputation
of the right leg” instead of the left leg that is to be amputated. The nurse has administered
already the preoperative medications. What should the nurse do?
A. Call the physician to reschedule the surgery.
B. Call the nearest relative to come in to sign a new form.
C. Cross out the error and initial the form.
D. Have the client sign another form.
1. A pregnant woman who is at term is admitted to the birthing unit in active labor. The client
has only progressed from 2cm to 3 cm in 8 hours. She is diagnosed with
hypotonic dystocia and the physician ordered Oxytocin (Pitocin) to augment her contractions.
Which of the following is the most important aspect of nursing intervention at this time?
A. Timing and recording length of contractions.
B. Monitoring.
C. Preparing for an emergency cesarean birth.
D. Checking the perineum for bulging.
2. A client who hallucinates is not in touch with reality. It is important for the nurse to:
A. Isolate the client from other patients.
B. Maintain a safe environment.
C. Orient the client to time, place, and person.
D. Establish a trusting relationship.
3. The nurse is caring to a child client who has had a tonsillectomy. The child complains of
having dryness of the throat. Which of the following would the nurse give to the child?
A. Cola with ice
B. Yellow noncitrus Jello
C. Cool cherry Kool-Aid
D. A glass of milk
4. The physician ordered Phenylephrine (Neo-Synephrine) nasal spray to a 13-year-old client.
The nurse caring to the client provides instructions that the nasal spray must be used exactly
as directed to prevent the development of:
A. Increased nasal congestion.
B. Nasal polyps.
C. Bleeding tendencies.
D. Tinnitus and diplopia.
,5. A client with tuberculosis is to be admitted in the hospital. The nurse who will be assigned
to care for the client must institute appropriate precautions. The nurse should:
A. Place the client in a private room.
B. Wear an N 95 respirator when caring for the client.
C. Put on a gown every time when entering the room.
D. Don a surgical mask with a face shield when entering the room.
6. Which of the following is the most frequent cause of noncompliance to the medical
treatment of open-angle glaucoma?
A. The frequent nausea and vomiting accompanying use of miotic drug.
B. Loss of mobility due to severe driving restrictions.
C. Decreased light and near-vision accommodation due to miotic effects of pilocarpine.
D. The painful and insidious progression of this type of glaucoma.
7. In the morning shift, the nurse is making rounds in the nursing care units. The nurse enters
in a client’s room and notes that the client’s tube has become disconnected from the
Pleurovac. What would be the initial nursing action?
A. Apply pressure directly over the incision site.
B. Clamp the chest tube near the incision site.
C. Clamp the chest tube closer to the drainage system.
D. Reconnect the chest tube to the Pleurovac.
8. Which of the following complications during a breech birth the nurse needs to be alarmed?
A. Abruption placenta.
B. Caput succedaneum.
C. Pathological hyperbilirubinemia.
D. Umbilical cord prolapse.
9. The nurse is caring to a client diagnosed with severe depression. Which of the following
nursing approach is important in depression?
,A. Protect the client against harm to others.
B. Provide the client with motor outlets for aggressive, hostile feelings.
C. Reduce interpersonal contacts.
D. Deemphasizing preoccupation with elimination, nourishment, and sleep.
10. A 3-month-old client is in the pediatric unit. During assessment, the nurse is suspecting
that the baby may have hypothyroidism when mother states that her baby does not:
A. Sit up.
B. Pick up and hold a rattle.
C. Roll over.
D. Hold the head up.
11. The physician calls the nursing unit to leave an order. The senior nurse had conversation
with the other staff. The newly hired nurse answers the phone so that the senior nurses may
continue their conversation. The new nurse does not knowthe physician or the client to whom
the order pertains. The nurse should:
A. Ask the physician to call back after the nurse has read the hospital policy manual.
B. Take the telephone order.
C. Refuse to take the telephone order.
D. Ask the charge nurse or one of the other senior staff nurses to take the telephone order.
12. The staff nurse on the labor and delivery unit is assigned to care to a primigravida in
transition complicated by hypertension. A new pregnant woman in active labor is admitted in
the same unit. The nurse manager assigned the same nurse to the second client. The nurse
feels that the client with hypertension requires one-to-one care. What would be the initial
actionof the nurse?
A. Accept the new assignment and complete an incident report describing a shortage of
nursing staff.
B. Report the incident to the nursing supervisor and request to be floated.
C. Report the nursing assessment of the client in transitional labor to the nurse manager and
discuss misgivings about the new assignment.
D. Accept the new assignment and provide the best care.
, 13. A newborn infant with Down syndrome is to be discharged today. The nurse is preparing
to give the discharge teaching regarding the proper care at home. The nurse would anticipate
that the mother is probably at the:
A. 40 years of age.
B. 20 years of age.
C. 35 years of age.
D. 20 years of age.
14. The emergency department has shortage of staff. The nurse manager informs the staff
nurse in the critical care unit that she has to float to the emergency department. What should
the staff nurse expect under these conditions?
A. The float staff nurse will be informed of the situation before the shift begins.
B. The staff nurse will be able to negotiate the assignments in the emergency department.
C. Cross training will be available for the staff nurse.
D. Client assignments will be equally divided among the nurses.
15. The nurse is assigned to care for a child client admitted in the pediatrics unit. The client is
receiving digoxin. Which of the following questions will be asked by the nurse to the parents
of the child in order to assess the client’s risk for digoxin toxicity?
A. “Has he been exposed to any childhood communicable diseases in the past 2-3 weeks?”
B. “Has he been taking diuretics at home?”
C. “Do any of his brothers and sisters have history of cardiac problems?”
D. “Has he been going to school regularly?”
16. The nurse noticed that the signed consent form has an error. The form states, “Amputation
of the right leg” instead of the left leg that is to be amputated. The nurse has administered
already the preoperative medications. What should the nurse do?
A. Call the physician to reschedule the surgery.
B. Call the nearest relative to come in to sign a new form.
C. Cross out the error and initial the form.
D. Have the client sign another form.
