Comprehensive Exam 2
During a home visit, the nurse notes that a female client with degenerative joint disease is
taking 3 grams of aspirin PO daily. The client complains of tinnitus, and seems confused. Which
intervention should the nurse implement?
Prepare a written schedule to remind the client when to take each dose of aspirin.
Observe the client place each dose in the correct boxes of her pill container.
Contact the client's healthcare provider to report the assessment findings.
Ask a family member to ensure that the client takes the medication as prescribed. -
ANS-Contact the client's healthcare provider to report the assessment findings.
Tinnitus and confusion are both signs of aspirin toxicity, which is consistent with the high dose of
aspirin that the client is taking. The healthcare provider should be notified of the symptoms to
determine further treatment. The other choices will likely increase the client's symptoms of
toxicity.
The nurse is informed that a client is returning to the unit from the post-anesthesia care unit
following abdominal surgery. Which task is best to delegate to the unlicensed assistive
personnel (UAP)?
Assess breathing pattern after transport is completed.
Notify the family that the client is returning from surgery.
Report to the charge nurse the appearance of the dressing.
Assist the transport team with transferring the client to the bed. - ANS-Assist the transport team
with transferring the client to the bed.
The UAP can be assigned to assist with transferring the client from the gurney to the bed since
repositioning following abdominal surgery is not a high-risk intervention and does not require
nursing judgment. Assessing breath sounds requires judgment and should be performed by a
licensed person. Notifying family should be done by the nurse who may provide additional
information if requested. The nurse should directly observe the dressing and should not rely on
the UAP's assessment of the dressing's appearance.
During the initial home visit, the nurse performs a family assessment. Which component is most
important for the nurse to consider?
The legal definition of family in the United States.
Members of the group that are direct descendents or bonded by marriage.
An exploration of the group relationships, structure, functions, and roles.
Cultural differences among members of the extended family. - ANS-An exploration of the group
relationships, structure, functions, and roles.
,Part of understanding an individual is determining the family members' relationships, functions,
and roles with one another in the group structure. Although the other options provide additional
data about the family members' relationships, the functions of the members in the group
provides clarification about decision making and responsibilities.
Which client is at greatest risk for multiple organ dysfunction syndrome (MODS)?
An older client with intestinal obstruction and septic shock.
A near-drowning victim with a history of respiratory arrest.
An adolescent with an autoimmune disease.
An adult male with a myocardial infarction and pericarditis. - ANS-An older client with intestinal
obstruction and septic shock.
High risk clients vulnerable for MODS include older clients with decreased organ reserve,
comorbidities, and massive inflammatory or immune dysfunction, such as septic shock, or
clients who have experienced various ischemia-reperfusion events related to trauma or surgical
complications. Although acute respiratory failure, respiratory arrest, or myocardial infarction may
be precursors to MODS, additional complications usually precipitate the pathological cascade of
hypermetabolism and excessive production of inflammatory and biochemical mediators that
cause widespread organ damage. An adolescent with autoimmune disease is at risk for MODS
only if complications such as massive infection, respiratory failure, or cardiac arrest occur.
A client has a precipitous delivery attended only by the nurse. What nursing intervention has the
highest priority?
Ensure an adequate airway in the newborn.
Massage the uterine fundus until it is firm.
Clamp and cut the umbilical cord.
Assess for signs of placental detachment. - ANS-Ensure an adequate airway in the newborn.
Ensuring an adequate airway in the newborn is the first intervention that should be
implemented. Suctioning of secretions should be performed immediately. Airway of newborn is
priority.
The nurse is teaching a client how to self-administer a subcutaneous injection. To help ensure
sterility of the procedure, which subject is most important for the nurse to include in the teaching
plan?
Hand washing prior to preparation of the injection.
Method used to aspirate medication from a vial.
Selection and rotation of injection sites.
Proper disposal of injection equipment. - ANS-Method used to aspirate medication from a vial.
,To maintain sterility of the procedure, the most important factor to include in the teaching plan is
how to manipulate the syringe parts so that the medication maintains sterility during the
preparation and administration. The other options are teaching topics, but are not components
of maintaining sterile technique while administering an injection.
A graduate nurse (GN) tells the RN preceptor, "I need to insert a nasogastric tube, and though I
was checked off on this procedure in my nursing school's simulation lab, I have never inserted
one on a real person." How should the preceptor respond?
"I must see documentation of successful check-off by your school's instructor."
"Performing the procedure on a simulator is different from performing it on a real person."
"Let's review the procedure, then I will supervise you while you perform the procedure."
"I will help you, but we need to inform the client that you are new at doing this." - ANS-"Let's
review the procedure, then I will supervise you while you perform the procedure."
Reviewing the procedure with the GN allows the preceptor to assess the GN's knowledge of the
procedure, and supervising this first-time procedure is the safest option for the client.
Documentation of a simulated experience does not negate the need to supervise the GN's first
experience. The GN is already aware of the difference of performing the skill on a real person,
which is why the issue was presented to the preceptor. Informing the client that the nurse is new
at performing the procedure is not necessary, but reviewing the procedure and supervising the
GN is necessary.
A woman visits the clinic for confirmation of pregnancy. All of her children from prior pregnancies
are living. One was born at 39-weeks gestation, twins at 34-weeks gestation, and another
singleton at 35-weeks gestation. How should the nurse record her gravity and parity using the
GTPAL system?
3-0-3-0-3.
3-1-1-1-3.
4-1-2-0-4.
4-2-1-0-3. - ANS-4-1-2-0-4.
Using the GPTAL system is the correct record of gravity and parity. G reflects the total number
of times the woman has been pregnant; she is pregnant for the 4th time. T indicates the number
of pregnancies carried to term, not the number of deliveries at term; she has had only one
pregnancy after 37-weeks gestation. P is the number of pregnancies that resulted in a preterm
birth, not the number of infants born; she has had two pregnancies before 37-weeks gestation.
A signifies elected abortions or miscarriages prior to the period of viability (20-weeks). L signifies
the number of children born that are currently living.
A male client, who has a 3-year history of Type 2 diabetes that is controlled by diet, is being
discharged postmyocardial infarction with a prescription of nitroglycerin tablets for chest pain
and regular insulin for treatment of his diabetes. Following teaching, the client tells the nurse
, that he will make sure he keeps his nitroglycerin bottle in his pants pocket at all times, that he
eats and drinks a snack before going to bed, and that he checks his blood glucose before eating
in the morning. This client requires further teaching on which subject?
Storing nitroglycerin.
Fluid intake.
Blood glucose monitoring.
Diabetic diet. - ANS-Storing nitroglycerin.
Nitroglycerin must be kept in the original dark-tinted, glass, screw-top bottle so that contact with
air can be avoided, and keeping it in a pants pocket exposes it to body heat, which can reduce
its effectiveness. The client should keep the medication in a jacket pocket, which would reduce
direct body contact with the bottle. He should also check the expiration date on the bottle (it is
good for 3 months and tingling in the mouth indicates that the drug is fresh). Some people
experience a headache when taking nitroglycerin, due to the vasodilatation effect.
A child weighing 44 pounds is receiving a bolus of Ringer's Lactate solution for fluid
replacement at 20 ml/kg. How many ml should the nurse administer? (Enter numeric value only.)
- ANS-400
Isotonic crystalloid solution (normal saline or lactated Ringer's solution) is usually the first choice
for fluid replacement in children and is given in IV boluses of 10 to 20 ml/kg over 10 to 15
minutes and repeated as necessary. First convert the pounds to kg, then multiply by 20 ml.
44 pounds 2.2 pounds/kg = 20 kg 20 ml = 400 ml.
After receiving chemotherapy 2 weeks ago, a male client with acute leukemia is admitted for
blood transfusions because his hemoglobin is 6 gm/dl. After toileting, the client returns to bed
and his oxygen saturation is measured at 82%. The nurse increases the O 2 per nasal cannula
from 3 to 4 liters per minute. What intervention should the nurse implement next?
Collect blood for hemoglobin and hematocrit.
Start the first transfusion of blood.
Insert an indwelling urinary catheter.
Encourage alternate rest periods with activity. - ANS-Start the first transfusion of blood.
The hemoglobin of 6 gm/dl (normal is 14 to 18 gm/dl in males) and the 82% O2 saturation
(normal is 96 to 100%) indicates the client is hypoxic, so the first transfusion of blood should be
started. Rechecking labs should be obtained after the client is transfused to evaluate its
effectiveness. Placing a catheter is not indicated at this time. Rest periods should be included in
the plan of care, but is not as essential as giving the transfusion at this time.
A multigravida at 41-weeks gestation is receiving an oxytocin (Pitocin) infusion for induction of
labor. The nurse notes the fetal heart rate (FHR) drops sharply from the baseline for 30 seconds
During a home visit, the nurse notes that a female client with degenerative joint disease is
taking 3 grams of aspirin PO daily. The client complains of tinnitus, and seems confused. Which
intervention should the nurse implement?
Prepare a written schedule to remind the client when to take each dose of aspirin.
Observe the client place each dose in the correct boxes of her pill container.
Contact the client's healthcare provider to report the assessment findings.
Ask a family member to ensure that the client takes the medication as prescribed. -
ANS-Contact the client's healthcare provider to report the assessment findings.
Tinnitus and confusion are both signs of aspirin toxicity, which is consistent with the high dose of
aspirin that the client is taking. The healthcare provider should be notified of the symptoms to
determine further treatment. The other choices will likely increase the client's symptoms of
toxicity.
The nurse is informed that a client is returning to the unit from the post-anesthesia care unit
following abdominal surgery. Which task is best to delegate to the unlicensed assistive
personnel (UAP)?
Assess breathing pattern after transport is completed.
Notify the family that the client is returning from surgery.
Report to the charge nurse the appearance of the dressing.
Assist the transport team with transferring the client to the bed. - ANS-Assist the transport team
with transferring the client to the bed.
The UAP can be assigned to assist with transferring the client from the gurney to the bed since
repositioning following abdominal surgery is not a high-risk intervention and does not require
nursing judgment. Assessing breath sounds requires judgment and should be performed by a
licensed person. Notifying family should be done by the nurse who may provide additional
information if requested. The nurse should directly observe the dressing and should not rely on
the UAP's assessment of the dressing's appearance.
During the initial home visit, the nurse performs a family assessment. Which component is most
important for the nurse to consider?
The legal definition of family in the United States.
Members of the group that are direct descendents or bonded by marriage.
An exploration of the group relationships, structure, functions, and roles.
Cultural differences among members of the extended family. - ANS-An exploration of the group
relationships, structure, functions, and roles.
,Part of understanding an individual is determining the family members' relationships, functions,
and roles with one another in the group structure. Although the other options provide additional
data about the family members' relationships, the functions of the members in the group
provides clarification about decision making and responsibilities.
Which client is at greatest risk for multiple organ dysfunction syndrome (MODS)?
An older client with intestinal obstruction and septic shock.
A near-drowning victim with a history of respiratory arrest.
An adolescent with an autoimmune disease.
An adult male with a myocardial infarction and pericarditis. - ANS-An older client with intestinal
obstruction and septic shock.
High risk clients vulnerable for MODS include older clients with decreased organ reserve,
comorbidities, and massive inflammatory or immune dysfunction, such as septic shock, or
clients who have experienced various ischemia-reperfusion events related to trauma or surgical
complications. Although acute respiratory failure, respiratory arrest, or myocardial infarction may
be precursors to MODS, additional complications usually precipitate the pathological cascade of
hypermetabolism and excessive production of inflammatory and biochemical mediators that
cause widespread organ damage. An adolescent with autoimmune disease is at risk for MODS
only if complications such as massive infection, respiratory failure, or cardiac arrest occur.
A client has a precipitous delivery attended only by the nurse. What nursing intervention has the
highest priority?
Ensure an adequate airway in the newborn.
Massage the uterine fundus until it is firm.
Clamp and cut the umbilical cord.
Assess for signs of placental detachment. - ANS-Ensure an adequate airway in the newborn.
Ensuring an adequate airway in the newborn is the first intervention that should be
implemented. Suctioning of secretions should be performed immediately. Airway of newborn is
priority.
The nurse is teaching a client how to self-administer a subcutaneous injection. To help ensure
sterility of the procedure, which subject is most important for the nurse to include in the teaching
plan?
Hand washing prior to preparation of the injection.
Method used to aspirate medication from a vial.
Selection and rotation of injection sites.
Proper disposal of injection equipment. - ANS-Method used to aspirate medication from a vial.
,To maintain sterility of the procedure, the most important factor to include in the teaching plan is
how to manipulate the syringe parts so that the medication maintains sterility during the
preparation and administration. The other options are teaching topics, but are not components
of maintaining sterile technique while administering an injection.
A graduate nurse (GN) tells the RN preceptor, "I need to insert a nasogastric tube, and though I
was checked off on this procedure in my nursing school's simulation lab, I have never inserted
one on a real person." How should the preceptor respond?
"I must see documentation of successful check-off by your school's instructor."
"Performing the procedure on a simulator is different from performing it on a real person."
"Let's review the procedure, then I will supervise you while you perform the procedure."
"I will help you, but we need to inform the client that you are new at doing this." - ANS-"Let's
review the procedure, then I will supervise you while you perform the procedure."
Reviewing the procedure with the GN allows the preceptor to assess the GN's knowledge of the
procedure, and supervising this first-time procedure is the safest option for the client.
Documentation of a simulated experience does not negate the need to supervise the GN's first
experience. The GN is already aware of the difference of performing the skill on a real person,
which is why the issue was presented to the preceptor. Informing the client that the nurse is new
at performing the procedure is not necessary, but reviewing the procedure and supervising the
GN is necessary.
A woman visits the clinic for confirmation of pregnancy. All of her children from prior pregnancies
are living. One was born at 39-weeks gestation, twins at 34-weeks gestation, and another
singleton at 35-weeks gestation. How should the nurse record her gravity and parity using the
GTPAL system?
3-0-3-0-3.
3-1-1-1-3.
4-1-2-0-4.
4-2-1-0-3. - ANS-4-1-2-0-4.
Using the GPTAL system is the correct record of gravity and parity. G reflects the total number
of times the woman has been pregnant; she is pregnant for the 4th time. T indicates the number
of pregnancies carried to term, not the number of deliveries at term; she has had only one
pregnancy after 37-weeks gestation. P is the number of pregnancies that resulted in a preterm
birth, not the number of infants born; she has had two pregnancies before 37-weeks gestation.
A signifies elected abortions or miscarriages prior to the period of viability (20-weeks). L signifies
the number of children born that are currently living.
A male client, who has a 3-year history of Type 2 diabetes that is controlled by diet, is being
discharged postmyocardial infarction with a prescription of nitroglycerin tablets for chest pain
and regular insulin for treatment of his diabetes. Following teaching, the client tells the nurse
, that he will make sure he keeps his nitroglycerin bottle in his pants pocket at all times, that he
eats and drinks a snack before going to bed, and that he checks his blood glucose before eating
in the morning. This client requires further teaching on which subject?
Storing nitroglycerin.
Fluid intake.
Blood glucose monitoring.
Diabetic diet. - ANS-Storing nitroglycerin.
Nitroglycerin must be kept in the original dark-tinted, glass, screw-top bottle so that contact with
air can be avoided, and keeping it in a pants pocket exposes it to body heat, which can reduce
its effectiveness. The client should keep the medication in a jacket pocket, which would reduce
direct body contact with the bottle. He should also check the expiration date on the bottle (it is
good for 3 months and tingling in the mouth indicates that the drug is fresh). Some people
experience a headache when taking nitroglycerin, due to the vasodilatation effect.
A child weighing 44 pounds is receiving a bolus of Ringer's Lactate solution for fluid
replacement at 20 ml/kg. How many ml should the nurse administer? (Enter numeric value only.)
- ANS-400
Isotonic crystalloid solution (normal saline or lactated Ringer's solution) is usually the first choice
for fluid replacement in children and is given in IV boluses of 10 to 20 ml/kg over 10 to 15
minutes and repeated as necessary. First convert the pounds to kg, then multiply by 20 ml.
44 pounds 2.2 pounds/kg = 20 kg 20 ml = 400 ml.
After receiving chemotherapy 2 weeks ago, a male client with acute leukemia is admitted for
blood transfusions because his hemoglobin is 6 gm/dl. After toileting, the client returns to bed
and his oxygen saturation is measured at 82%. The nurse increases the O 2 per nasal cannula
from 3 to 4 liters per minute. What intervention should the nurse implement next?
Collect blood for hemoglobin and hematocrit.
Start the first transfusion of blood.
Insert an indwelling urinary catheter.
Encourage alternate rest periods with activity. - ANS-Start the first transfusion of blood.
The hemoglobin of 6 gm/dl (normal is 14 to 18 gm/dl in males) and the 82% O2 saturation
(normal is 96 to 100%) indicates the client is hypoxic, so the first transfusion of blood should be
started. Rechecking labs should be obtained after the client is transfused to evaluate its
effectiveness. Placing a catheter is not indicated at this time. Rest periods should be included in
the plan of care, but is not as essential as giving the transfusion at this time.
A multigravida at 41-weeks gestation is receiving an oxytocin (Pitocin) infusion for induction of
labor. The nurse notes the fetal heart rate (FHR) drops sharply from the baseline for 30 seconds
