Standard quizzes Comprehensive Final
and answers with solutions
A nurse is teaching the parent of a child who has severe reactive airway disease about
glucocorticoid therapy. The parent asks why her child has to inhale the medication instead of
taking it orally. Which of the following information should the nurse provide the parent? -
ANSWER Oral glucocorticoids are more like to slow linear growth in children. (Chronic use of
oral glucocorticoids in high doses by children can result in decreased linear growth. Inhaled
glucocorticoids deliver the anti-inflammatory agent directly to the local target area (pts airways)
resulting in an decreased risk for adrenal suppression).
A nurse is providing teaching to a client who has come to the family planning clinic requesting
an intrauterine device (IUD). Which of the following information should the nurse provide the
client? - ANSWER "Your risk of ectopic pregnancy increases with an IUD." [An IUD is a family
planning device the provider inserts through the cervix into the uterus to prevent pregnancy.
The IUD works by changing the lining of the uterus and fallopian tubes, making fertilization in
the uterus more difficult. Consequently, an IUD increases the risk for ectopic pregnancy.]
A nurse is assessing a preschooler who has recurrent and persistent otitis media. When
obtaining the child's history from her parent, which of the following questions should the nurse
ask? - ANSWER "Does anyone smoke around or in the same house as your child?" [Otitis media
is an infection of the middle ear. Passive smoking promotes adherence of respiratory pathogens
to the lining of the middle ear space. It also prolongs the inflammation and impedes drainage
from the ear.]
A nurse is providing teaching to a client who has a new prescription for sertraline. The client
asks the nurse if he should continue to take St. John's wort for depression. Which of the
following instructions should the nurse give the client? - ANSWER Stop taking the herbal
supplement while taking the medication. [Taking the antidepressant sertraline and the herbal
supplement St. John's wort together puts the client at risk for serotonin syndrome.]
,A nurse is caring for a client who is receiving bleomycin IV to treat lymphoma. Which of the
following assessments is the nurse's priority? - ANSWER Pulmonary function [The nurse should
apply the safety and risk reduction priority-setting framework. This framework assigns priority
to the factor or situation posing the greatest safety risk to the client. When there are several
risks to client safety, the one posing the greatest threat is the highest priority. The nurse should
use Maslow's Hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to
identify which risk poses the greatest threat to the client. Bleomycin can cause severe lung
injury, including pneumonitis and pulmonary fibrosis, and it affects a significant percentage of
clients receiving this medication; therefore, pulmonary function is the priority assessment.]
A nurse is teaching a client how to use an albuterol metered dose inhaler. After removing the
cap from the inhaler and shaking the canister, identify the sequence of instructions the nurse
should give the client. (Move the steps into the box on the right, placing them in the selected
order of performance. Use all the steps.) - ANSWER 1. The client should hold the mouthpiece 2-
4 cm (1-2 in) from his mouth 2. Tilt his head back slightly, and then open his mouth 3. Next, he
should depress the medication canister while taking a deep breath to facilitate delivery of the
medication through the airway 4. After holding his breath for 10 seconds, the client should
resume his usual breathing pattern.
A nurse is reviewing the laboratory report for a client who has chronic kidney disease (CKD). The
nurse finds the following laboratory test results: potassium 6.8 mEq/L, calcium 7.4 mg/dL,
hemoglobin 10.2 g/dL, and phosphate 4.8 mg/dL. Which of the following findings is the priority
for the nurse to report to the provider? - ANSWER Hyperkalemia [The nurse should apply the
urgent versus nonurgent priority-setting framework when caring for this client. Using this
framework, the nurse should consider urgent needs the priority need because they pose more
of a threat to the client. The nurse may also need to use Maslow's hierarchy of needs, the ABC
priority-setting framework, or nursing knowledge to identify which finding is the most urgent.
Therefore, hyperkalemia, which can cause life-threatening cardiac dysrhythmias, is the priority
for the nurse to report to the provider.
A nurse is facilitating a group discussion with preschool teachers about child abuse. Which of
the following data should the nurse use as a common example of a suggestive finding? -
ANSWER Arm cast for a spiral fracture of the forearm [Spiral fractures occur from twisting of an
extremity. In most instances, spiral fractures of the arm result from an abusive injury.]
,Due to staffing shortages, a nurse manager floats a medical-surgical nurse to the pediatric unit.
The nurse has limited experience with children. Which of the following actions should the nurse
manager take? - ANSWER Assign a unit nurse to act as a resource to act as a resource for the
medical-surgical nurse. [Assigning a nurse who usually works on the pediatric unit to work with
the medical-surgical nurse will provide consistent support]
A nurse is developing a plan of care for a client who has gastroesophageal reflux disease (GERD).
The nurse should plan to monitor the client for which of the following complications? - ANSWER
Aspiration [Aspiration is a common complication of GERD, which results when the esophageal
sphincter malfunctions, allowing gastric acid and undigested food to back up into the
esophagus. This places the client at risk for aspiration. GERD causes effortless, uncontrolled
regurgitation whether the client is in an upright position or reclining. The most common results
of regurgitation are heartburn and indigestion; however, aspiration is also possible. Therefore,
the nurse should monitor the client for crackles in the lung fields, which is an indication of
aspiration.]
A client at a routine prenatal care visit asks the nurse if it is common to develop vaginal yeast
infections during pregnancy. Which of the following responses should the nurse make? -
ANSWER "The hormonal changes of pregnancy change the acidity of the vagina, making yeast
infections more common." [This is an information-seeking question; therefore, the therapeutic
response is an answer that provides the client with the information she requested.]
A community health nurse is performing client triage while participating in a disaster drill. The
nurse should recommend that which of the following clients receives treatment first? - ANSWER
Hemothorax [The nurse should apply the survival potential priority-setting framework. The
nurse should reserve the use of this framework for mass casualty situations, when resources are
scarce and he must allocate resources to save the greatest number of lives. While it might seem
that the client least likely to survive should receive priority care, this is the client who is the
lowest priority. The nurse should assign the highest priority to the client who has injuries that
are severe but has the potential to survive with treatment. Therefore, the nurse should
recommend that the client who has a hemothorax receive treatment first. A hemothorax is life-
threatening, but with chest-tube insertion and stabilization the client is likely to survive.
, A nurse is providing teaching to a school-age child who has just had a fiberglass cast application
following lower extremity fracture. Which of the following instructions should the nurse give the
child and his parents about care during the first 48 hours? - ANSWER "Keep the cast above the
level of your heart." [Immediately following the injury, and for at least the first 48 hours, the
child should keep the affected limb above the level of the heart to help prevent edema and pain
and to promote venous return.]
A nurse is assessing a toddler who has AIDS. The nurse should identify which of the following
findings as an indication of an opportunistic infection? - ANSWER Candidiasis [Candidiasis, or
oral thrush, results from the overgrowth of Candida albicans, an opportunistic fungus that
commonly infects the oral cavity of clients who have immature or compromised immune
systems. Candidiasis appears as a cheesy, white plaque that looks like milk curds on the buccal
mucosa and tongue. Thrush is often the initial opportunistic infection in an HIV-positive child
who is developing AIDS.]
A nurse is assessing a client who has an abdominal aortic aneurysm (AAA). Which of the
following findings should indicate to the nurse that the AAA is expanding? - ANSWER Report of
sudden, severe back pain [An aortic aneurysm is a weak spot in the wall of the aorta, the
primary artery that carries blood from the heart to the head and extremities, that allows the
aorta to expand and increase in diameter. Sudden and increasing lower abdominal and back
pain indicates that the aneurysm is extending downward and pressing on the lumbar sacral
nerve roots.]
A nurse is providing discharge teaching to a client who does not speak the same language as the
nurse. The client's neighbor, who speaks the client's native language and the nurse's, arrives to
drive the client home. Which of the following actions should the nurse take? - ANSWER Obtain
the services of an interpreter [Federal mandates require that a professional medical interpreter
translate the client's health care information into the client's native language.]
A nurse is caring for a client who is receiving IV ampicillin and develops urticaria and dyspnea.
Which of the following actions should the nurse take first? - ANSWER Stop the medication
infusion [The greatest risk to the client is an allergic reaction that can progress to anaphylaxis.
The nurse should stop the infusion immediately to halt further exposure of the client to the
allergen.]
and answers with solutions
A nurse is teaching the parent of a child who has severe reactive airway disease about
glucocorticoid therapy. The parent asks why her child has to inhale the medication instead of
taking it orally. Which of the following information should the nurse provide the parent? -
ANSWER Oral glucocorticoids are more like to slow linear growth in children. (Chronic use of
oral glucocorticoids in high doses by children can result in decreased linear growth. Inhaled
glucocorticoids deliver the anti-inflammatory agent directly to the local target area (pts airways)
resulting in an decreased risk for adrenal suppression).
A nurse is providing teaching to a client who has come to the family planning clinic requesting
an intrauterine device (IUD). Which of the following information should the nurse provide the
client? - ANSWER "Your risk of ectopic pregnancy increases with an IUD." [An IUD is a family
planning device the provider inserts through the cervix into the uterus to prevent pregnancy.
The IUD works by changing the lining of the uterus and fallopian tubes, making fertilization in
the uterus more difficult. Consequently, an IUD increases the risk for ectopic pregnancy.]
A nurse is assessing a preschooler who has recurrent and persistent otitis media. When
obtaining the child's history from her parent, which of the following questions should the nurse
ask? - ANSWER "Does anyone smoke around or in the same house as your child?" [Otitis media
is an infection of the middle ear. Passive smoking promotes adherence of respiratory pathogens
to the lining of the middle ear space. It also prolongs the inflammation and impedes drainage
from the ear.]
A nurse is providing teaching to a client who has a new prescription for sertraline. The client
asks the nurse if he should continue to take St. John's wort for depression. Which of the
following instructions should the nurse give the client? - ANSWER Stop taking the herbal
supplement while taking the medication. [Taking the antidepressant sertraline and the herbal
supplement St. John's wort together puts the client at risk for serotonin syndrome.]
,A nurse is caring for a client who is receiving bleomycin IV to treat lymphoma. Which of the
following assessments is the nurse's priority? - ANSWER Pulmonary function [The nurse should
apply the safety and risk reduction priority-setting framework. This framework assigns priority
to the factor or situation posing the greatest safety risk to the client. When there are several
risks to client safety, the one posing the greatest threat is the highest priority. The nurse should
use Maslow's Hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to
identify which risk poses the greatest threat to the client. Bleomycin can cause severe lung
injury, including pneumonitis and pulmonary fibrosis, and it affects a significant percentage of
clients receiving this medication; therefore, pulmonary function is the priority assessment.]
A nurse is teaching a client how to use an albuterol metered dose inhaler. After removing the
cap from the inhaler and shaking the canister, identify the sequence of instructions the nurse
should give the client. (Move the steps into the box on the right, placing them in the selected
order of performance. Use all the steps.) - ANSWER 1. The client should hold the mouthpiece 2-
4 cm (1-2 in) from his mouth 2. Tilt his head back slightly, and then open his mouth 3. Next, he
should depress the medication canister while taking a deep breath to facilitate delivery of the
medication through the airway 4. After holding his breath for 10 seconds, the client should
resume his usual breathing pattern.
A nurse is reviewing the laboratory report for a client who has chronic kidney disease (CKD). The
nurse finds the following laboratory test results: potassium 6.8 mEq/L, calcium 7.4 mg/dL,
hemoglobin 10.2 g/dL, and phosphate 4.8 mg/dL. Which of the following findings is the priority
for the nurse to report to the provider? - ANSWER Hyperkalemia [The nurse should apply the
urgent versus nonurgent priority-setting framework when caring for this client. Using this
framework, the nurse should consider urgent needs the priority need because they pose more
of a threat to the client. The nurse may also need to use Maslow's hierarchy of needs, the ABC
priority-setting framework, or nursing knowledge to identify which finding is the most urgent.
Therefore, hyperkalemia, which can cause life-threatening cardiac dysrhythmias, is the priority
for the nurse to report to the provider.
A nurse is facilitating a group discussion with preschool teachers about child abuse. Which of
the following data should the nurse use as a common example of a suggestive finding? -
ANSWER Arm cast for a spiral fracture of the forearm [Spiral fractures occur from twisting of an
extremity. In most instances, spiral fractures of the arm result from an abusive injury.]
,Due to staffing shortages, a nurse manager floats a medical-surgical nurse to the pediatric unit.
The nurse has limited experience with children. Which of the following actions should the nurse
manager take? - ANSWER Assign a unit nurse to act as a resource to act as a resource for the
medical-surgical nurse. [Assigning a nurse who usually works on the pediatric unit to work with
the medical-surgical nurse will provide consistent support]
A nurse is developing a plan of care for a client who has gastroesophageal reflux disease (GERD).
The nurse should plan to monitor the client for which of the following complications? - ANSWER
Aspiration [Aspiration is a common complication of GERD, which results when the esophageal
sphincter malfunctions, allowing gastric acid and undigested food to back up into the
esophagus. This places the client at risk for aspiration. GERD causes effortless, uncontrolled
regurgitation whether the client is in an upright position or reclining. The most common results
of regurgitation are heartburn and indigestion; however, aspiration is also possible. Therefore,
the nurse should monitor the client for crackles in the lung fields, which is an indication of
aspiration.]
A client at a routine prenatal care visit asks the nurse if it is common to develop vaginal yeast
infections during pregnancy. Which of the following responses should the nurse make? -
ANSWER "The hormonal changes of pregnancy change the acidity of the vagina, making yeast
infections more common." [This is an information-seeking question; therefore, the therapeutic
response is an answer that provides the client with the information she requested.]
A community health nurse is performing client triage while participating in a disaster drill. The
nurse should recommend that which of the following clients receives treatment first? - ANSWER
Hemothorax [The nurse should apply the survival potential priority-setting framework. The
nurse should reserve the use of this framework for mass casualty situations, when resources are
scarce and he must allocate resources to save the greatest number of lives. While it might seem
that the client least likely to survive should receive priority care, this is the client who is the
lowest priority. The nurse should assign the highest priority to the client who has injuries that
are severe but has the potential to survive with treatment. Therefore, the nurse should
recommend that the client who has a hemothorax receive treatment first. A hemothorax is life-
threatening, but with chest-tube insertion and stabilization the client is likely to survive.
, A nurse is providing teaching to a school-age child who has just had a fiberglass cast application
following lower extremity fracture. Which of the following instructions should the nurse give the
child and his parents about care during the first 48 hours? - ANSWER "Keep the cast above the
level of your heart." [Immediately following the injury, and for at least the first 48 hours, the
child should keep the affected limb above the level of the heart to help prevent edema and pain
and to promote venous return.]
A nurse is assessing a toddler who has AIDS. The nurse should identify which of the following
findings as an indication of an opportunistic infection? - ANSWER Candidiasis [Candidiasis, or
oral thrush, results from the overgrowth of Candida albicans, an opportunistic fungus that
commonly infects the oral cavity of clients who have immature or compromised immune
systems. Candidiasis appears as a cheesy, white plaque that looks like milk curds on the buccal
mucosa and tongue. Thrush is often the initial opportunistic infection in an HIV-positive child
who is developing AIDS.]
A nurse is assessing a client who has an abdominal aortic aneurysm (AAA). Which of the
following findings should indicate to the nurse that the AAA is expanding? - ANSWER Report of
sudden, severe back pain [An aortic aneurysm is a weak spot in the wall of the aorta, the
primary artery that carries blood from the heart to the head and extremities, that allows the
aorta to expand and increase in diameter. Sudden and increasing lower abdominal and back
pain indicates that the aneurysm is extending downward and pressing on the lumbar sacral
nerve roots.]
A nurse is providing discharge teaching to a client who does not speak the same language as the
nurse. The client's neighbor, who speaks the client's native language and the nurse's, arrives to
drive the client home. Which of the following actions should the nurse take? - ANSWER Obtain
the services of an interpreter [Federal mandates require that a professional medical interpreter
translate the client's health care information into the client's native language.]
A nurse is caring for a client who is receiving IV ampicillin and develops urticaria and dyspnea.
Which of the following actions should the nurse take first? - ANSWER Stop the medication
infusion [The greatest risk to the client is an allergic reaction that can progress to anaphylaxis.
The nurse should stop the infusion immediately to halt further exposure of the client to the
allergen.]
