Comp predictor B
A nurse is preparing to replace a patient's transdermal fentanyl patch after 72 hours of use. After
opening the packet with the new pouch, the patient refuses to accept it. Which action should the
nurse take?
A) Withhold pain medications for 24 hr after the old patch is removed.
B) Ask another nurse to witness the disposal of the new patch.
C) Seal the patches in a plastic bag and place in the client's trash basket.
D) Stick the two patches to each other and place them in the sharps bin. - CORRECT
ANSWER-B) Ask another nurse to witness the disposal of the new patch.
A nurse is caring for a client with a PE. The client is receiving heparin IV at 1,200 units/hr and
warfarin 5 mg PO daily. The morning lab values are aPTT 98 seconds and INR 1.8. Which action
should the nurse take?
A) Prepare to administer vitamin K1.
B) Prepare to administer alteplase.
C) Withhold the heparin infusion.
D) Withhold the next dose of warfarin. - CORRECT ANSWER-C) Withhold the heparin infusion.
The expected value for aPTT is 40 seconds. A therapeutic level of heparin increases the aPTT by
a factor of 1.5 to 2, making the aPTT 60 to 80 seconds. An aPTT level of 98 is above the expected
reference range, indicating that the dosage should be reduced or the infusion withheld until the
aPTT returns to the therapeutic range.
A nurse at an urgent care clinic is assessing a patient with impaired vision in 1 eye. Which report
from the patient should indicate to the nurse that the client has a detached retina?
A) Halos around lights
B) Floating dark spots
C) Pain in the affected eye
D) Cloudy vision - CORRECT ANSWER-B) Floating dark spots
A nurse is assessing an infant with hydrocephalus and is 6 hours post-op following placement of a
VP shunt. Which finding should the nurse report to the provider?
A) Heart rate 122/min
B) Irritability when being held
C) Hypoactive bowel sounds
D) Urine specific gravity 1.018 - CORRECT ANSWER-B) Irritability when being held
A nurse is assessing a newborn's HR. Which action should the nurse take?
A) Assess the apical pulse while the newborn is crying to detect cardiac problems.
B) Palpate the radial pulse and determine the rate based on number of beats per minute.
C) Listen to the apical pulse while palpating the radial pulse to detect variance.
D) Auscultate the apical pulse and count beats for at least 1 min. - CORRECT ANSWER-D)
Auscultate the apical pulse and count beats for at least 1 min.
A nurse is caring for a client with a fecal impaction. Which action should the nurse take when
digitally evacuating the stool?
A) Place the client in the lithotomy position.
B) Elicit a vagal response by performing gentle rectal stimulation.
C) Administer oral bisacodyl 30 min prior to the procedure.
,D) Insert a lubricated gloved finger and advance along the rectal wall. - CORRECT ANSWER-D)
Insert a lubricated gloved finger and advance along the rectal wall.
A nurse is providing dietary teaching to a patient taking phenelzine. Which food recommendations
should the nurse make? (Select all)
A) Broccoli
B) Yogurt
C) Pepperoni pizza
D) Cream cheese
E) Bologna sandwich - CORRECT ANSWER-A) Broccoli
B) Yogurt
D) Cream cheese
A nurse administers an incorrect dose of a med to a client. The nurse recognizes the error
immediately and completes an incident report. Which fact related to the incident should the nurse
document in the client's medical record?
A) Completion of the incident report
B) Time the medication was given
C) Reason for the medication error
D) Notification of the pharmacist - CORRECT ANSWER-B) Time the medication was given
A nurse on a pediatric unit received report on 4 children. Which child should the nurse assess
first?
A) A 6-month-old infant who has croup and an O2 saturation of 92% on room air
B) A 15-year-old adolescent who is 2 hr postoperative following an open reduction and internal
fixation of the left ankle and is requesting pain medication
C) A 3-year-old toddler who has gastroenteritis, moderate dehydration, and had two loose bowel
movements over the past 24 hr
D) A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden
relief from pain - CORRECT ANSWER-D) A 10-year-old child who is awaiting surgery for an
appendectomy and experienced sudden relief from pain
Using the urgent vs. non-urgent approach to client care, the nurse should determine that the client
to assess first is the child awaiting an appendectomy who suddenly experiences pain relief as this
can be an indication of peritonitis from a ruptured appendix.
A community health nurse is providing teaching about home safety with a group of elderly clients.
Which statement should the nurse make?
A) "Unplug your appliances by grasping the cord and pulling it straight from the outlet."
B) "Set your water heater temperature at 130 degrees Fahrenheit."
C) "Use throw rugs in high-traffic areas to partially cover wood floors."
D) "Have grab bars installed around your bathtub and toilet." - CORRECT ANSWER-D) "Have
grab bars installed around your bathtub and toilet."
A nurse in the ED is assessing a school-age child who was brought in by her parents and has
scald burns to both hands and wrists. The nurse suspects physical abuse. Which action should the
nurse take?
A) Discuss his suspicion of physical abuse with the provider.
B) Confront the parents with his suspicion of physical abuse.
C) Ask the hospital security to detain and question the parents.
D) Contact child protective services. - CORRECT ANSWER-D) Contact child protective services.
, A nurse is caring for a patient with acute blood loss following a trauma. The patient refuses a
blood transfusion that could save his life. Which action should the nurse take first?
A) Document the client's refusal in the medical record.
B) Honor the client's decision to refuse the blood transfusion.
C) Explore the client's reasons for refusing the treatment.
D) Discuss the client's refusal with the provider. - CORRECT ANSWER-C) Explore the client's
reasons for refusing the treatment.
A nurse is teaching a client at 20 weeks gestation about common prenatal discomfort. Which
statement by the client indicates an understanding of the teaching?
A) "I will decrease my intake of high-fiber foods."
B) "I will apply an anti-inflammatory ointment if I develop a rash on my face."
C) "I will sleep flat on my back if I develop back pain."
D) "I will wear a supportive bra overnight." - CORRECT ANSWER-D) "I will wear a supportive bra
overnight."
A nurse is providing discharge education to a patient who is to receive home oxygen therapy.
Which instruction should the nurse include in the teaching?
A) Check the functioning of oxygen equipment once each week.
B) Wear clothing made with cotton fabrics while oxygen is in use.
C) Apply petroleum-based lubricant to the nares as needed.
D) Store full oxygen tanks on their side. - CORRECT ANSWER-B) Wear clothing made with cotton
fabrics while oxygen is in use.
The nurse should teach the client to apply a water-soluble lubricant to soothe irritation of the
mucous membranes, because products containing oils are flammable when near oxygen.
A nurse manager is preparing an education session about advocacy to a group of nurses. The
nurse manager should include what information in the teaching?
A) Advocacy is a leadership role that helps others to self-actualize.
B) Subordinates are an advocate for the nurse manager.
C) Advocacy is to encourage client dependence in decision making.
D) Nurse managers should distrust people who speak out about harmful or inappropriate
professional practices. - CORRECT ANSWER-A) Advocacy is a leadership role that helps others
to self-actualize.
A nurse is caring for a patient receiving continuous bladder irrigation following a transurethral
resection of the prostate. The patient reports bladder spasms and the nurse observes a decreased
urinary output. Which action should the nurse take?
A) Increase tension on the urinary catheter.
B) Irrigate the catheter with 0.9% sodium chloride irrigation.
C) Assist the client to ambulate.
D) Remove the urinary catheter immediately. - CORRECT ANSWER-B) Irrigate the catheter with
0.9% sodium chloride irrigation.
Decreased urine output and bladder spasms indicate internal obstructions of the catheter.
Therefore, the nurse should irrigate the catheter with 0.9% sodium chloride irrigation and notify the
provider if the obstruction does not clear.
A nurse is preparing to replace a patient's transdermal fentanyl patch after 72 hours of use. After
opening the packet with the new pouch, the patient refuses to accept it. Which action should the
nurse take?
A) Withhold pain medications for 24 hr after the old patch is removed.
B) Ask another nurse to witness the disposal of the new patch.
C) Seal the patches in a plastic bag and place in the client's trash basket.
D) Stick the two patches to each other and place them in the sharps bin. - CORRECT
ANSWER-B) Ask another nurse to witness the disposal of the new patch.
A nurse is caring for a client with a PE. The client is receiving heparin IV at 1,200 units/hr and
warfarin 5 mg PO daily. The morning lab values are aPTT 98 seconds and INR 1.8. Which action
should the nurse take?
A) Prepare to administer vitamin K1.
B) Prepare to administer alteplase.
C) Withhold the heparin infusion.
D) Withhold the next dose of warfarin. - CORRECT ANSWER-C) Withhold the heparin infusion.
The expected value for aPTT is 40 seconds. A therapeutic level of heparin increases the aPTT by
a factor of 1.5 to 2, making the aPTT 60 to 80 seconds. An aPTT level of 98 is above the expected
reference range, indicating that the dosage should be reduced or the infusion withheld until the
aPTT returns to the therapeutic range.
A nurse at an urgent care clinic is assessing a patient with impaired vision in 1 eye. Which report
from the patient should indicate to the nurse that the client has a detached retina?
A) Halos around lights
B) Floating dark spots
C) Pain in the affected eye
D) Cloudy vision - CORRECT ANSWER-B) Floating dark spots
A nurse is assessing an infant with hydrocephalus and is 6 hours post-op following placement of a
VP shunt. Which finding should the nurse report to the provider?
A) Heart rate 122/min
B) Irritability when being held
C) Hypoactive bowel sounds
D) Urine specific gravity 1.018 - CORRECT ANSWER-B) Irritability when being held
A nurse is assessing a newborn's HR. Which action should the nurse take?
A) Assess the apical pulse while the newborn is crying to detect cardiac problems.
B) Palpate the radial pulse and determine the rate based on number of beats per minute.
C) Listen to the apical pulse while palpating the radial pulse to detect variance.
D) Auscultate the apical pulse and count beats for at least 1 min. - CORRECT ANSWER-D)
Auscultate the apical pulse and count beats for at least 1 min.
A nurse is caring for a client with a fecal impaction. Which action should the nurse take when
digitally evacuating the stool?
A) Place the client in the lithotomy position.
B) Elicit a vagal response by performing gentle rectal stimulation.
C) Administer oral bisacodyl 30 min prior to the procedure.
,D) Insert a lubricated gloved finger and advance along the rectal wall. - CORRECT ANSWER-D)
Insert a lubricated gloved finger and advance along the rectal wall.
A nurse is providing dietary teaching to a patient taking phenelzine. Which food recommendations
should the nurse make? (Select all)
A) Broccoli
B) Yogurt
C) Pepperoni pizza
D) Cream cheese
E) Bologna sandwich - CORRECT ANSWER-A) Broccoli
B) Yogurt
D) Cream cheese
A nurse administers an incorrect dose of a med to a client. The nurse recognizes the error
immediately and completes an incident report. Which fact related to the incident should the nurse
document in the client's medical record?
A) Completion of the incident report
B) Time the medication was given
C) Reason for the medication error
D) Notification of the pharmacist - CORRECT ANSWER-B) Time the medication was given
A nurse on a pediatric unit received report on 4 children. Which child should the nurse assess
first?
A) A 6-month-old infant who has croup and an O2 saturation of 92% on room air
B) A 15-year-old adolescent who is 2 hr postoperative following an open reduction and internal
fixation of the left ankle and is requesting pain medication
C) A 3-year-old toddler who has gastroenteritis, moderate dehydration, and had two loose bowel
movements over the past 24 hr
D) A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden
relief from pain - CORRECT ANSWER-D) A 10-year-old child who is awaiting surgery for an
appendectomy and experienced sudden relief from pain
Using the urgent vs. non-urgent approach to client care, the nurse should determine that the client
to assess first is the child awaiting an appendectomy who suddenly experiences pain relief as this
can be an indication of peritonitis from a ruptured appendix.
A community health nurse is providing teaching about home safety with a group of elderly clients.
Which statement should the nurse make?
A) "Unplug your appliances by grasping the cord and pulling it straight from the outlet."
B) "Set your water heater temperature at 130 degrees Fahrenheit."
C) "Use throw rugs in high-traffic areas to partially cover wood floors."
D) "Have grab bars installed around your bathtub and toilet." - CORRECT ANSWER-D) "Have
grab bars installed around your bathtub and toilet."
A nurse in the ED is assessing a school-age child who was brought in by her parents and has
scald burns to both hands and wrists. The nurse suspects physical abuse. Which action should the
nurse take?
A) Discuss his suspicion of physical abuse with the provider.
B) Confront the parents with his suspicion of physical abuse.
C) Ask the hospital security to detain and question the parents.
D) Contact child protective services. - CORRECT ANSWER-D) Contact child protective services.
, A nurse is caring for a patient with acute blood loss following a trauma. The patient refuses a
blood transfusion that could save his life. Which action should the nurse take first?
A) Document the client's refusal in the medical record.
B) Honor the client's decision to refuse the blood transfusion.
C) Explore the client's reasons for refusing the treatment.
D) Discuss the client's refusal with the provider. - CORRECT ANSWER-C) Explore the client's
reasons for refusing the treatment.
A nurse is teaching a client at 20 weeks gestation about common prenatal discomfort. Which
statement by the client indicates an understanding of the teaching?
A) "I will decrease my intake of high-fiber foods."
B) "I will apply an anti-inflammatory ointment if I develop a rash on my face."
C) "I will sleep flat on my back if I develop back pain."
D) "I will wear a supportive bra overnight." - CORRECT ANSWER-D) "I will wear a supportive bra
overnight."
A nurse is providing discharge education to a patient who is to receive home oxygen therapy.
Which instruction should the nurse include in the teaching?
A) Check the functioning of oxygen equipment once each week.
B) Wear clothing made with cotton fabrics while oxygen is in use.
C) Apply petroleum-based lubricant to the nares as needed.
D) Store full oxygen tanks on their side. - CORRECT ANSWER-B) Wear clothing made with cotton
fabrics while oxygen is in use.
The nurse should teach the client to apply a water-soluble lubricant to soothe irritation of the
mucous membranes, because products containing oils are flammable when near oxygen.
A nurse manager is preparing an education session about advocacy to a group of nurses. The
nurse manager should include what information in the teaching?
A) Advocacy is a leadership role that helps others to self-actualize.
B) Subordinates are an advocate for the nurse manager.
C) Advocacy is to encourage client dependence in decision making.
D) Nurse managers should distrust people who speak out about harmful or inappropriate
professional practices. - CORRECT ANSWER-A) Advocacy is a leadership role that helps others
to self-actualize.
A nurse is caring for a patient receiving continuous bladder irrigation following a transurethral
resection of the prostate. The patient reports bladder spasms and the nurse observes a decreased
urinary output. Which action should the nurse take?
A) Increase tension on the urinary catheter.
B) Irrigate the catheter with 0.9% sodium chloride irrigation.
C) Assist the client to ambulate.
D) Remove the urinary catheter immediately. - CORRECT ANSWER-B) Irrigate the catheter with
0.9% sodium chloride irrigation.
Decreased urine output and bladder spasms indicate internal obstructions of the catheter.
Therefore, the nurse should irrigate the catheter with 0.9% sodium chloride irrigation and notify the
provider if the obstruction does not clear.
