Comprehensive Exam 3
Role of Respiratory Therapist, Physical Therapist, Occupational Therapist, Speech
Therapist
1. The nurse is caring for the following assigned clients. The nurse should refer to the? A.
Respiratory therapist, the client who has chronic obstructive pulmonary disease (COPD)
and has developed dysphagia.
B. Occupational therapist, the client who had a stroke and needs instruction on the use of
kitchen tools.
C. Psychiatrist, the client who has terminal cancer and is requesting to complete an
advance directive
D. Speech therapist, the client who had outpatient surgery and needs an interpreter for
discharge instructions
Additional Question:
The nurse is caring for the following assigned clients. The nurse should refer to the?
a. OT stroke and needs instruction on use of a walker.
b. Patient with COPD who just developed dysphagia to a speech therapist. Rationale:
OT assists with ADLs, instruction on the use of a walker would be referred to physical therapy.
Delegation
2. The nurse working on a medical-surgical unit is delegating tasks to UAP. Which of the
following tasks would require follow up by the charge nurse?
A. Providing catheter care to a client who has a catheter-associated urinary tract infection
(CAUTI).
B. Taking the vital signs of a client who returned from the postanesthesia care unit (PACU)
C. Assisting a client who had a paracentesis two hours ago to get out of bed for the first
time.
D. Assisting a client who had a total hip arthroplasty to transfer from the bed to the chair for
the second time since surgery.
Prioritization (Acute Pancreatitis, Myasthenia Gravis, PAD, COPD)
3. The nurse working on the medical-surgical unit has just received a hand-off report on
assigned clients. The nurse should first plan to assess the client who has A. Acute pancreatitis
and is reporting the development of pain on deep inspiration. B. A history of myasthenia gravis
and has developed ptosis of the eyelid. C. Peripheral artery disease (PAD) and reports a
burning pain in the calf that occurs when walking.
D. COPD who intermittently coughs up a moderate amount of secretions.
Sterile Field
4. The nurse is reviewing prescriptions for assigned clients. Which of the following should the
nurse question?
A. Remove chest tube and apply a sterile dressing
B. Type and crossmatch for 2 units of packed red blood cells (PRBCs)
, C. Complete a Glasgow coma scale (GCS) assessment every 1 hour
D. Irrigate the Jackson-Pratt drain every 4 hours with 5 mL of normal saline (NS) Rationale:
The nurse would question this because you should apply an occlusive dressing, NOT a sterile
dressing.
Proper sterile field:
➔Open flap furthest from you first
➔Place a sterile package 1 inch from the border.
➔Hold sterile object above waist level
➔Open a sterile package 6 inches in the middle above another sterile field?
Clients Rights
5. The nurse working on a pediatric unit is caring for a client who is scheduled to have
electroconvulsive therapy (ECT) treatment the next day. The client asks, “Can I refuse the ECT
treatment tomorrow?” Which of the following responses should the nurse make? A. “You have
already given signed consent to treatment.”
B. “I think you might feel better after you have the treatment.”
C. “Let’s talk with your doctor before you make a final decision.”
D. “You have a right to refuse even though you have signed the consent.”
?
6. The nurse working on a pediatric unit is caring for the following assigned clients. The nurse
should recommend an interdisciplinary conference for the client who
A. Was diagnosed with cystic fibrosis (CF) and has a distended abdomen
B. Is 10 hours postoperative and just urinated 30 mL of clear yellow urine
C. Is receiving hemodialysis and is reporting they feel itchy all over
D. Was diagnosed with norovirus and is experiencing acute diarrhea
?
7. The nurse is teaching a client who has pelvic inflammatory disease about self-care. The
client does not speak English. Which of the following actions should the nurse take? A. Ask an
unlicensed assistive personnel (UAP) who speaks the client’s language to serve as an
interpreter
B. Have a family member who speaks both English and the client’s languager interpret the
instruction
C. Contact the charge nurse to obtain assistance from a facility-approved interpreter
D. Utilize a translation dictionary found on the unit to conduct the teaching
Prioritization (Lyme Disease, Graves Disease, Pleurisy, Polycystic Kidney Disease
(PKD)) 8. The nurse working in a community health clinic is assessing clients who are waiting
to be seen. Which of the following clients should the nurse have the PHCP see first? A.
57-year-old who has Graves disease and has developed a temperature of 100.5 F within
the past two hours.
Role of Respiratory Therapist, Physical Therapist, Occupational Therapist, Speech
Therapist
1. The nurse is caring for the following assigned clients. The nurse should refer to the? A.
Respiratory therapist, the client who has chronic obstructive pulmonary disease (COPD)
and has developed dysphagia.
B. Occupational therapist, the client who had a stroke and needs instruction on the use of
kitchen tools.
C. Psychiatrist, the client who has terminal cancer and is requesting to complete an
advance directive
D. Speech therapist, the client who had outpatient surgery and needs an interpreter for
discharge instructions
Additional Question:
The nurse is caring for the following assigned clients. The nurse should refer to the?
a. OT stroke and needs instruction on use of a walker.
b. Patient with COPD who just developed dysphagia to a speech therapist. Rationale:
OT assists with ADLs, instruction on the use of a walker would be referred to physical therapy.
Delegation
2. The nurse working on a medical-surgical unit is delegating tasks to UAP. Which of the
following tasks would require follow up by the charge nurse?
A. Providing catheter care to a client who has a catheter-associated urinary tract infection
(CAUTI).
B. Taking the vital signs of a client who returned from the postanesthesia care unit (PACU)
C. Assisting a client who had a paracentesis two hours ago to get out of bed for the first
time.
D. Assisting a client who had a total hip arthroplasty to transfer from the bed to the chair for
the second time since surgery.
Prioritization (Acute Pancreatitis, Myasthenia Gravis, PAD, COPD)
3. The nurse working on the medical-surgical unit has just received a hand-off report on
assigned clients. The nurse should first plan to assess the client who has A. Acute pancreatitis
and is reporting the development of pain on deep inspiration. B. A history of myasthenia gravis
and has developed ptosis of the eyelid. C. Peripheral artery disease (PAD) and reports a
burning pain in the calf that occurs when walking.
D. COPD who intermittently coughs up a moderate amount of secretions.
Sterile Field
4. The nurse is reviewing prescriptions for assigned clients. Which of the following should the
nurse question?
A. Remove chest tube and apply a sterile dressing
B. Type and crossmatch for 2 units of packed red blood cells (PRBCs)
, C. Complete a Glasgow coma scale (GCS) assessment every 1 hour
D. Irrigate the Jackson-Pratt drain every 4 hours with 5 mL of normal saline (NS) Rationale:
The nurse would question this because you should apply an occlusive dressing, NOT a sterile
dressing.
Proper sterile field:
➔Open flap furthest from you first
➔Place a sterile package 1 inch from the border.
➔Hold sterile object above waist level
➔Open a sterile package 6 inches in the middle above another sterile field?
Clients Rights
5. The nurse working on a pediatric unit is caring for a client who is scheduled to have
electroconvulsive therapy (ECT) treatment the next day. The client asks, “Can I refuse the ECT
treatment tomorrow?” Which of the following responses should the nurse make? A. “You have
already given signed consent to treatment.”
B. “I think you might feel better after you have the treatment.”
C. “Let’s talk with your doctor before you make a final decision.”
D. “You have a right to refuse even though you have signed the consent.”
?
6. The nurse working on a pediatric unit is caring for the following assigned clients. The nurse
should recommend an interdisciplinary conference for the client who
A. Was diagnosed with cystic fibrosis (CF) and has a distended abdomen
B. Is 10 hours postoperative and just urinated 30 mL of clear yellow urine
C. Is receiving hemodialysis and is reporting they feel itchy all over
D. Was diagnosed with norovirus and is experiencing acute diarrhea
?
7. The nurse is teaching a client who has pelvic inflammatory disease about self-care. The
client does not speak English. Which of the following actions should the nurse take? A. Ask an
unlicensed assistive personnel (UAP) who speaks the client’s language to serve as an
interpreter
B. Have a family member who speaks both English and the client’s languager interpret the
instruction
C. Contact the charge nurse to obtain assistance from a facility-approved interpreter
D. Utilize a translation dictionary found on the unit to conduct the teaching
Prioritization (Lyme Disease, Graves Disease, Pleurisy, Polycystic Kidney Disease
(PKD)) 8. The nurse working in a community health clinic is assessing clients who are waiting
to be seen. Which of the following clients should the nurse have the PHCP see first? A.
57-year-old who has Graves disease and has developed a temperature of 100.5 F within
the past two hours.
