RN Comprehensive Practice B
A charge nurse is providing an educational session about infection control for a group of
staff nurses. Which of the following statements by one of the staff nurses indicated an
understanding of isolation precautions? - ANS - "A client who requires airborne
precautions should be placed in a negative pressure airflow room"
\A charge nurse is speaking with the partner of a client. The partner states that the client
is not receiving adequate care. Which of the following actions should the charge nurse
take first to resolve the situation? - ANS - Ask the partner to list specific concerns
\A charge nurse notices that one of the nurses on the shift frequently violates unit
policies by taking an extended amount of time for break. Which of the following
statements should the charge nurse make to address this conflict? - ANS - "I would like
to talk to you about the unit policies regarding break time"
\A client is receiving IV fluids at 150 mL/hr. Which of the following findings indicates that
the client is experiencing fluid overload? - ANS - Dyspnea
Fluid overload can lead to the backup of fluid in the pulmonary system resulting in
shortness of breath.
\A home health nurse is caring for a group of older adult clients. The nurse should
indicate a referral to the Program of All-Inclusive Care for the Elderly (PACE) for which
of the following clients? - ANS - A client whose caregiver requests adult day care
services
PACE provides adult day care services along with in-home assessments and supportive
services
\A home health nurse is developing a teaching plan for a client who has a new
ileostomy. Which of the following instructions should the nurse include? - ANS - Empty
the appliance when it is one-third to one-half full
To prevent stool leakage and skin irritation
\A home health nurse is evaluating a school age child who has cystic fibrosis. The nurse
should initiate a request for a high-frequency chest compression vest in response to
which of the following parent statements? - ANS - "My child has only a small amount of
mucus after percussion therapy"
\A hospice nurse is consulting with a client and her family about receiving home
services. Which of the following statements should the nurse identify as an indication
that the family understands home hospice care? - ANS - "We can expect the hospice
nurse to provide support for us after our mother's death"
,\A nurse administers an incorrect dose of medication to a client. The nurse recognized
the error immediately and completes and incident report. Which of the following facts
related to the incident should the nurse document in the client's medical record? - ANS -
Time the medication was given
\A nurse at a mental health clinic is caring for four clients. The nurse should recognize
the following clients is using dissociation as a defense mechanism? - ANS - A client
who was abused as a child describes the abuse as if it happened to someone else
\A nurse at an urgent care clinic is assessing a client who reports impaired vision in one
eye. Which of the following reports by the client should indicate to the nurse that the
client has a detached retina? - ANS - Floating dark spots
\A nurse has just received change of shift report on four clients. Which of the following
clients should the nurse assess first? - ANS - A client who is postoperative with
abdominal distention and no bowel sounds
- abdominal distention and no bowel sounds indicates a paralytic ileus
\A nurse has received change of shift report on four assigned clients. For which of the
following clients should the nurse intervene to prevent a potential food and medication
interaction? - ANS - A client who is receiving an MAOI and is requesting a
cheeseburger for dinner
- The client's food selection contains tyramine. Clients prescribed an MAOI must restrict
intake of foods that contain tyramine due to adverse effects, such as HTN
\A nurse in a community center is providing an education session to a group of clients
about ovarian cancer. Which of the following manifestations of ovarian cancer should
the nurse include in the teaching? - ANS - Abdominal bloating
\A nurse in a mental health clinic is assessing a client who has a history of seeking
counseling for relationship problems. The client shows the nurse multiple superficial
self-inflicted lacerations on their forearms. The nurse should identify these behaviors as
characteristics of which of the following personality disorders? - ANS - Borderline
Clients who have borderline personality disorder tend to be emotionally unstable, have
troubled interpersonal relationships, and often engage in harmful behaviors such as
cutting, substance use, and suicidal ideation.
\A nurse in a provider's office is assess an adolescent who has been taking ibuprofen
for 6 months to treat juvenile idiopathic arthritis. Which of the following questions should
the nurse ask to assess for an adverse effect of this medication? - ANS - "Have you had
any stomach pain or bloody stools?"
\A nurse in a provider's office is caring for an 18 month old toddler who has a blood lead
level of 3 mcg/dL. Which of the following actions should the nurse take? - ANS -
Recommend rescreening in 1 year
, - A blood lead level of 3 mcg/dL is within the expected reference range. The nurse
should schedule chelation therapy for a blood lead level greater than 45 mcg/dL. The
nurse should contact the poison control center for a blood lead level that is greater than
20 mcg/dL. The nurse should consider a referral to social services for a blood lead level
greater than 5 mcg/dL.
\A nurse in an emergency department is assessing a school age child who was brought
in by their parents and has scald burns to both hands and wrists. The nurse suspects
physical abuse. Which of the following actions should the nurse take? - ANS - Contact
Child Protective Services
\A nurse in an emergency department is caring for a child who has a fever and
fluid-filled vesicles on the trunk and extremities. Which of the following interventions
should the nurse identify as the priority? - ANS - Initiate transmission-based precautions
The child most likely has varicella. Therefore, the nurse should isolate the child to
prevent the spread of the infection.
\A nurse in an emergency department is caring for a client who is at 9 weeks of
gestation and reports nausea and vomiting for the past 2 days. Which of the following
findings should the nurse expect? - ANS - Urine specific gravity 1.052
The nurse should recognize this urine specific gravity is significantly elevated above the
expected reference range of 1.005 to 1.030. An increased urine specific gravity
indicates dehydration from vomiting.
\A nurse in an emergency department is caring for a client who is unconscious and
requires emergency medical procedures. The nurse in unable to locate members of the
client's family to obtain consent. Which of the following actions should the nurse take? -
ANS - Proceed with provision of medical care
\A nurse in an outpatient mental health clinic is caring for four clients. The nurse should
recognize that which of the following clients is effectively using sublimation as a defense
mechanism? - ANS - A client who channels their energy into a new hobby following the
loss of their job
\A nurse in an outpatient mental health facility is assessing a child who has autism
spectrum disorder. Which of the following manifestations should the nurse expect? -
ANS - Strict adherence to routines
\A nurse in the emergency department is assessing a preschooler who has a facial
laceration. The nurse should identify which of the following findings as a potential
indication of child sexual abuse? - ANS - The child exhibits discomfort while walking
\A nurse is admitting a client to the psychiatric unit after attempting suicide. The client
states, "My family does not care whether I live or die." Which of the following responses
should the nurse make? - ANS - "How does this make you feel?"
A charge nurse is providing an educational session about infection control for a group of
staff nurses. Which of the following statements by one of the staff nurses indicated an
understanding of isolation precautions? - ANS - "A client who requires airborne
precautions should be placed in a negative pressure airflow room"
\A charge nurse is speaking with the partner of a client. The partner states that the client
is not receiving adequate care. Which of the following actions should the charge nurse
take first to resolve the situation? - ANS - Ask the partner to list specific concerns
\A charge nurse notices that one of the nurses on the shift frequently violates unit
policies by taking an extended amount of time for break. Which of the following
statements should the charge nurse make to address this conflict? - ANS - "I would like
to talk to you about the unit policies regarding break time"
\A client is receiving IV fluids at 150 mL/hr. Which of the following findings indicates that
the client is experiencing fluid overload? - ANS - Dyspnea
Fluid overload can lead to the backup of fluid in the pulmonary system resulting in
shortness of breath.
\A home health nurse is caring for a group of older adult clients. The nurse should
indicate a referral to the Program of All-Inclusive Care for the Elderly (PACE) for which
of the following clients? - ANS - A client whose caregiver requests adult day care
services
PACE provides adult day care services along with in-home assessments and supportive
services
\A home health nurse is developing a teaching plan for a client who has a new
ileostomy. Which of the following instructions should the nurse include? - ANS - Empty
the appliance when it is one-third to one-half full
To prevent stool leakage and skin irritation
\A home health nurse is evaluating a school age child who has cystic fibrosis. The nurse
should initiate a request for a high-frequency chest compression vest in response to
which of the following parent statements? - ANS - "My child has only a small amount of
mucus after percussion therapy"
\A hospice nurse is consulting with a client and her family about receiving home
services. Which of the following statements should the nurse identify as an indication
that the family understands home hospice care? - ANS - "We can expect the hospice
nurse to provide support for us after our mother's death"
,\A nurse administers an incorrect dose of medication to a client. The nurse recognized
the error immediately and completes and incident report. Which of the following facts
related to the incident should the nurse document in the client's medical record? - ANS -
Time the medication was given
\A nurse at a mental health clinic is caring for four clients. The nurse should recognize
the following clients is using dissociation as a defense mechanism? - ANS - A client
who was abused as a child describes the abuse as if it happened to someone else
\A nurse at an urgent care clinic is assessing a client who reports impaired vision in one
eye. Which of the following reports by the client should indicate to the nurse that the
client has a detached retina? - ANS - Floating dark spots
\A nurse has just received change of shift report on four clients. Which of the following
clients should the nurse assess first? - ANS - A client who is postoperative with
abdominal distention and no bowel sounds
- abdominal distention and no bowel sounds indicates a paralytic ileus
\A nurse has received change of shift report on four assigned clients. For which of the
following clients should the nurse intervene to prevent a potential food and medication
interaction? - ANS - A client who is receiving an MAOI and is requesting a
cheeseburger for dinner
- The client's food selection contains tyramine. Clients prescribed an MAOI must restrict
intake of foods that contain tyramine due to adverse effects, such as HTN
\A nurse in a community center is providing an education session to a group of clients
about ovarian cancer. Which of the following manifestations of ovarian cancer should
the nurse include in the teaching? - ANS - Abdominal bloating
\A nurse in a mental health clinic is assessing a client who has a history of seeking
counseling for relationship problems. The client shows the nurse multiple superficial
self-inflicted lacerations on their forearms. The nurse should identify these behaviors as
characteristics of which of the following personality disorders? - ANS - Borderline
Clients who have borderline personality disorder tend to be emotionally unstable, have
troubled interpersonal relationships, and often engage in harmful behaviors such as
cutting, substance use, and suicidal ideation.
\A nurse in a provider's office is assess an adolescent who has been taking ibuprofen
for 6 months to treat juvenile idiopathic arthritis. Which of the following questions should
the nurse ask to assess for an adverse effect of this medication? - ANS - "Have you had
any stomach pain or bloody stools?"
\A nurse in a provider's office is caring for an 18 month old toddler who has a blood lead
level of 3 mcg/dL. Which of the following actions should the nurse take? - ANS -
Recommend rescreening in 1 year
, - A blood lead level of 3 mcg/dL is within the expected reference range. The nurse
should schedule chelation therapy for a blood lead level greater than 45 mcg/dL. The
nurse should contact the poison control center for a blood lead level that is greater than
20 mcg/dL. The nurse should consider a referral to social services for a blood lead level
greater than 5 mcg/dL.
\A nurse in an emergency department is assessing a school age child who was brought
in by their parents and has scald burns to both hands and wrists. The nurse suspects
physical abuse. Which of the following actions should the nurse take? - ANS - Contact
Child Protective Services
\A nurse in an emergency department is caring for a child who has a fever and
fluid-filled vesicles on the trunk and extremities. Which of the following interventions
should the nurse identify as the priority? - ANS - Initiate transmission-based precautions
The child most likely has varicella. Therefore, the nurse should isolate the child to
prevent the spread of the infection.
\A nurse in an emergency department is caring for a client who is at 9 weeks of
gestation and reports nausea and vomiting for the past 2 days. Which of the following
findings should the nurse expect? - ANS - Urine specific gravity 1.052
The nurse should recognize this urine specific gravity is significantly elevated above the
expected reference range of 1.005 to 1.030. An increased urine specific gravity
indicates dehydration from vomiting.
\A nurse in an emergency department is caring for a client who is unconscious and
requires emergency medical procedures. The nurse in unable to locate members of the
client's family to obtain consent. Which of the following actions should the nurse take? -
ANS - Proceed with provision of medical care
\A nurse in an outpatient mental health clinic is caring for four clients. The nurse should
recognize that which of the following clients is effectively using sublimation as a defense
mechanism? - ANS - A client who channels their energy into a new hobby following the
loss of their job
\A nurse in an outpatient mental health facility is assessing a child who has autism
spectrum disorder. Which of the following manifestations should the nurse expect? -
ANS - Strict adherence to routines
\A nurse in the emergency department is assessing a preschooler who has a facial
laceration. The nurse should identify which of the following findings as a potential
indication of child sexual abuse? - ANS - The child exhibits discomfort while walking
\A nurse is admitting a client to the psychiatric unit after attempting suicide. The client
states, "My family does not care whether I live or die." Which of the following responses
should the nurse make? - ANS - "How does this make you feel?"
