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NSG 4800 ALL COMPS Questions and
Answers A+ Graded
1. The nurse is providing discharge instructions to the family of an older adult
client who is bedridden. The nurse should instruct the family that the most
effective way to prevent urinary incontinence associated with immobility is to
1.apply a barrier moisture cream.
2.use absorbent under pads.
3.set up a toileting schedule.
4.restrict fluid intake. - ANSWER 3; set up a schedule
2. Four clients recently returned to the unit following invasive diagnostic testing.
The nurse should immediately intervene if one of the clients: (Scroll for Answer)
A. Reports blood-tinged sputum following a bronchoscopy
B.Has decreased abdominal girth following paracentesis
C.Reports a headache following a lumbar puncture
D.Is observed flexing and extending the legs two hours after femoral cardiac
catheterization - ANSWER D.
Following cardiac catheterization of the femoral artery, the client remains on
bedrest for 2 to 6 hours with the affected leg straight and the head of the bed
elevated to 30 degrees; blood tinged sputum is an expected finding after
bronchoscopy; removal of fluid from the peritoneal cavity as in paracentesis will
result in decreased abdominal girth; post lumbar puncture headache ranging from
mild to severe may appear a few hours to days following the procedure.
3. The registered nurse from the postpartum unit has been temporarily assigned to
the medical-surgical unit. It would be most appropriate to assign this nurse to the
client who
A.has returned from right total hip replacement surgery four hours ago
B.is being observed for increased intracranial pressure
C.had surgery two hours ago to remove the appendix
D.is two weeks post-partum being maintained on a mechanical ventilator for
respiratory failure - ANSWER C
The management of a client following abdominal surgery is standard. The
postpartum nurse routinely cares for mothers following caesarean section;
therefore it is appropriate to assign this client; The other choices are not
appropriate to assign to this nurse.
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4. The nurse manager of a medical-surgical unit is asked to select the hospitalized
clients who can be discharged so that hospital beds can be made available for
victims of a community disaster. Which clients can be safely discharged? Select all
that apply. (Scroll for Answer)
1.Client postoperative day 1 after inguinal herniorrhaphy, vital signs stable
2.Client 5 days after a myocardial infarction, vital signs stable, absence of
dysrhythmias
3.Client 1 day after cardiac catheterization, normal study results, groin site free of
hematoma
4.Client who is vomiting, unable to take oral fluids, and receiving intravenous
fluids at 125 mL/hr
5.Client on nasal oxygen at 3 L/min, bibasilar crackles, and pulse oximetry
readings of 88% to 92%
6.Client with white blood cell count of 2200 mm3(2.2 × 109/L), temperature of
102°F (38.9°C), and blood pressure of 90/40 mm Hg - ANSWER 1,2,3 Clients in
options 1, 2, and 3 demonstrate no evidence of instability and can be discharged
safely. The client in option 4 is demonstrating impaired gas exchange and fluid
overload and requires oxygen. The client in option 5 requires intravenous fluid
replacement because of vomiting. Without fluid replacement, the client is at risk
for dehydration and electrolyte imbalances. The client in option 6 demonstrates
signs of infection and hemodynamic instability and is at risk for developing septic
shock. These clients should not be discharged at this time.
5. The nurse is preparing to care for a client with a potassium deficit. The nurse
reviews the client's record and determines that the client is at risk for developing
the potassium deficit because of which situation? (Scroll for Answer)
Sustained tissue damage
Requires nasogastric suction
Has a history of Addison's disease
Uric acid level of 9.4 mg/dL (559 mmol/L) - ANSWER 2, The normal serum
potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium deficit is
known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through
gastrointestinal suction, placing the client at risk for hypokalemia. The client with
tissue damage or Addison's disease and the client with hyperuricemia are at risk for
hyperkalemia. The normal uric acid level for a female is 2.7 to 7.3 mg/dL (16 to
0.43 mmol/L) and for a male is 4.0 to 8.5 mg/dL (0.24 to 0.51 mmol/L).
Hyperuricemia is a cause of hyperkalemia.
6. A male client has a tentative diagnosis of urethritis. The nurse should assess the
client for which manifestation of the disorder? (Scroll for Answer)
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Hematuria and pyuria
Hematuria and urgency
Dysuria and proteinuria
Dysuria and penile discharge - ANSWER 4, Urethritis in the male client often
results from chlamydial infection and is characterized by dysuria, which is
accompanied by a clear to mucopurulent discharge. Because this disorder often
coexists with gonorrhea, diagnostic tests are done for both and include culture and
rapid assays. Hematuria is not associated with urethritis. Proteinuria is associated
with kidney dysfunction.
7. The nurse is monitoring a client in the immediate postpartum period for signs of
hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss?
A .temperature of 100.4°F (38°C)
B. An increase in the pulse rate from 88 to 102 beats/minute
C. A blood pressure change from 130/88 to 124/80 mm Hg
D. An increase in the respiratory rate from 18 to 22 breaths/minute - ANSWER B,
During the fourth stage of labor, the maternal blood pressure, pulse, and respiration
should be checked every 15 minutes during the first hour. An increasing pulse is an
early sign of excessive blood loss because the heart pumps faster to compensate for
reduced blood volume. A slight increase in temperature is normal. The blood
pressure decreases as the blood volume diminishes, but a decreased blood pressure
would not be the earliest sign of hemorrhage. The respiratory rate is slightly
increased from normal.
8. The nurse in the ambulatory care unit is providing home care instructions to a
client after cryotherapy for the treatment of malignant skin lesions. Which
statement would be most appropriate for the nurse to include in the home care
instructions for this client?
"Apply ice to the site to prevent swelling."
"Clean the site with alcohol 3 times daily."
"Apply a warm, damp washcloth if discomfort occurs."
"Avoid showering or taking baths until seen by the health care provider in 1 week."
- ANSWER 3, Cryotherapy involves the local application of liquid nitrogen to the
lesion; this causes cell death and tissue destruction. Tissue freezing is followed in 1
to 2 days by hemorrhagic blister formation; therefore, ice is not applied to the site.
The application of a warm, damp washcloth intermittently to the site will provide
relief of any discomfort. The nurse instructs the client to clean the site with the
prescribed solution to prevent secondary infection. A topical antibiotic also may be
prescribed. Alcohol would cause irritation to the skin. There is no reason for the
client to avoid showering or bathing.
NSG 4800 ALL COMPS Questions and
Answers A+ Graded
1. The nurse is providing discharge instructions to the family of an older adult
client who is bedridden. The nurse should instruct the family that the most
effective way to prevent urinary incontinence associated with immobility is to
1.apply a barrier moisture cream.
2.use absorbent under pads.
3.set up a toileting schedule.
4.restrict fluid intake. - ANSWER 3; set up a schedule
2. Four clients recently returned to the unit following invasive diagnostic testing.
The nurse should immediately intervene if one of the clients: (Scroll for Answer)
A. Reports blood-tinged sputum following a bronchoscopy
B.Has decreased abdominal girth following paracentesis
C.Reports a headache following a lumbar puncture
D.Is observed flexing and extending the legs two hours after femoral cardiac
catheterization - ANSWER D.
Following cardiac catheterization of the femoral artery, the client remains on
bedrest for 2 to 6 hours with the affected leg straight and the head of the bed
elevated to 30 degrees; blood tinged sputum is an expected finding after
bronchoscopy; removal of fluid from the peritoneal cavity as in paracentesis will
result in decreased abdominal girth; post lumbar puncture headache ranging from
mild to severe may appear a few hours to days following the procedure.
3. The registered nurse from the postpartum unit has been temporarily assigned to
the medical-surgical unit. It would be most appropriate to assign this nurse to the
client who
A.has returned from right total hip replacement surgery four hours ago
B.is being observed for increased intracranial pressure
C.had surgery two hours ago to remove the appendix
D.is two weeks post-partum being maintained on a mechanical ventilator for
respiratory failure - ANSWER C
The management of a client following abdominal surgery is standard. The
postpartum nurse routinely cares for mothers following caesarean section;
therefore it is appropriate to assign this client; The other choices are not
appropriate to assign to this nurse.
, 2
4. The nurse manager of a medical-surgical unit is asked to select the hospitalized
clients who can be discharged so that hospital beds can be made available for
victims of a community disaster. Which clients can be safely discharged? Select all
that apply. (Scroll for Answer)
1.Client postoperative day 1 after inguinal herniorrhaphy, vital signs stable
2.Client 5 days after a myocardial infarction, vital signs stable, absence of
dysrhythmias
3.Client 1 day after cardiac catheterization, normal study results, groin site free of
hematoma
4.Client who is vomiting, unable to take oral fluids, and receiving intravenous
fluids at 125 mL/hr
5.Client on nasal oxygen at 3 L/min, bibasilar crackles, and pulse oximetry
readings of 88% to 92%
6.Client with white blood cell count of 2200 mm3(2.2 × 109/L), temperature of
102°F (38.9°C), and blood pressure of 90/40 mm Hg - ANSWER 1,2,3 Clients in
options 1, 2, and 3 demonstrate no evidence of instability and can be discharged
safely. The client in option 4 is demonstrating impaired gas exchange and fluid
overload and requires oxygen. The client in option 5 requires intravenous fluid
replacement because of vomiting. Without fluid replacement, the client is at risk
for dehydration and electrolyte imbalances. The client in option 6 demonstrates
signs of infection and hemodynamic instability and is at risk for developing septic
shock. These clients should not be discharged at this time.
5. The nurse is preparing to care for a client with a potassium deficit. The nurse
reviews the client's record and determines that the client is at risk for developing
the potassium deficit because of which situation? (Scroll for Answer)
Sustained tissue damage
Requires nasogastric suction
Has a history of Addison's disease
Uric acid level of 9.4 mg/dL (559 mmol/L) - ANSWER 2, The normal serum
potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium deficit is
known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through
gastrointestinal suction, placing the client at risk for hypokalemia. The client with
tissue damage or Addison's disease and the client with hyperuricemia are at risk for
hyperkalemia. The normal uric acid level for a female is 2.7 to 7.3 mg/dL (16 to
0.43 mmol/L) and for a male is 4.0 to 8.5 mg/dL (0.24 to 0.51 mmol/L).
Hyperuricemia is a cause of hyperkalemia.
6. A male client has a tentative diagnosis of urethritis. The nurse should assess the
client for which manifestation of the disorder? (Scroll for Answer)
, 3
Hematuria and pyuria
Hematuria and urgency
Dysuria and proteinuria
Dysuria and penile discharge - ANSWER 4, Urethritis in the male client often
results from chlamydial infection and is characterized by dysuria, which is
accompanied by a clear to mucopurulent discharge. Because this disorder often
coexists with gonorrhea, diagnostic tests are done for both and include culture and
rapid assays. Hematuria is not associated with urethritis. Proteinuria is associated
with kidney dysfunction.
7. The nurse is monitoring a client in the immediate postpartum period for signs of
hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss?
A .temperature of 100.4°F (38°C)
B. An increase in the pulse rate from 88 to 102 beats/minute
C. A blood pressure change from 130/88 to 124/80 mm Hg
D. An increase in the respiratory rate from 18 to 22 breaths/minute - ANSWER B,
During the fourth stage of labor, the maternal blood pressure, pulse, and respiration
should be checked every 15 minutes during the first hour. An increasing pulse is an
early sign of excessive blood loss because the heart pumps faster to compensate for
reduced blood volume. A slight increase in temperature is normal. The blood
pressure decreases as the blood volume diminishes, but a decreased blood pressure
would not be the earliest sign of hemorrhage. The respiratory rate is slightly
increased from normal.
8. The nurse in the ambulatory care unit is providing home care instructions to a
client after cryotherapy for the treatment of malignant skin lesions. Which
statement would be most appropriate for the nurse to include in the home care
instructions for this client?
"Apply ice to the site to prevent swelling."
"Clean the site with alcohol 3 times daily."
"Apply a warm, damp washcloth if discomfort occurs."
"Avoid showering or taking baths until seen by the health care provider in 1 week."
- ANSWER 3, Cryotherapy involves the local application of liquid nitrogen to the
lesion; this causes cell death and tissue destruction. Tissue freezing is followed in 1
to 2 days by hemorrhagic blister formation; therefore, ice is not applied to the site.
The application of a warm, damp washcloth intermittently to the site will provide
relief of any discomfort. The nurse instructs the client to clean the site with the
prescribed solution to prevent secondary infection. A topical antibiotic also may be
prescribed. Alcohol would cause irritation to the skin. There is no reason for the
client to avoid showering or bathing.
